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Full text of "The American journal of the medical sciences"

*4i 




Property of the 

Lancaster City and County 
Medical Society 



No 



THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 

ISAAC HAYS/ M.D., 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; MEMBER OF THE 
AMERICAN MEDICAL ASSOCIATION ; OF THE AMERICAN PHILOSOPHICAL SOCIETY ; OF THE 
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA ; ASSOCIATE FELLOW 
OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES, 

&e. &c. &c. 



NEW SERIES. 
YOL. XLII. 




PHILADELPHIA: 
BLANCHAED AND LEA. 
1861. 



69468 



Entered according to the Act of Congress, in the year 1861, by 
BLANCHARD AND LEA, 

in the Office of the Clerk of the District Court of the United States in and for the 
Eastern District of the State of Pennsylvania. 




PHILADELPHIA 
COLLINS, PRIX TEE. 



ki'0.5 



TO READERS AND CORRESPONDENTS. 

The communications of Frof. Dalton, Drs. Read, Irwin, Griscom, Prince, 
Hitchcock, and Bradford are on file for publication. 

The following works have been received : — 

The History of Medicine; comprising a narrative of its progress from the 
earliest ages to the present time, and of the delusions incidental to its advance 
from empiricism to the dignity of science. By Edward Meryon, M. D., F. G. S., 
&c. &c. &c. Yol. I. London: Longman & Co., 1861. (From the Author.) 

Transactions of the Obstetrical Society of London. Yol. II. For the year 

1860. London: Longman & Co., 1861. (From the Society.) 

Relatorio do Gabinete Estatistico Medico-Cirurgico do Hospital Geral da Santa 
Casa de Misericordia e Enfermarias publicas apresentado ao Ex mo Sr. Marquez 
D'Abrantes Provedor da Santa Casa. Pelo Dr. Luiz da Silva Brandao, Di- 
rector do Gabinete Estatistico Medico Effectivo do Hospital do Santa Casa da 
Miseracordia, &c. &c. &c. Rio de Janeiro, 1860. (FrGm Dr. de Cunha, of Rio 
de Janeiro.) 

Another Letter to a Young Physician ; to which are appended some other 
Medical Papers. By James Jackson, M. D., Professor Emeritus of Theory and 
Pract. Med. in Harvard University. Boston : Ticknor & Fields, 1861. (From 
the Author.) 

Handbook for the Military Surgeon. By Charles S. Tripler, A.M., M.D., 
Surgeon U. S. A.; and George C. Blackman, M. D., &c. Cincinnati: Robert 
Clarke & Co., 1861. (From the Publishers.) 

A Manual of Military Surgery; or, Hints on the Emergencies of Field, Camp, 
and Hospital Practice. Illustrated with wood-cuts. By S. D. Gross, M. D., 
Prof. Surg. Jeff. Med. College. Philad. : J. B. Lippincott & Co., 1861. (From 
the Publishers.) 

A Practical Treatise on Military Surgery. By Frank Hastings Hamilton, 
M. D., Prof. Military Surgery and Diseases and Accidents incident to Bones in 
Bellevue Hospital, &c. &c. &c. New York : Bailliere & Bros., 1861. 

A Treatise on the Practice of Medicine. By Edwin R. Maxon, M. D., for- 
merly Lecturer on Insts. and Pract. Med. in Geneva Med. Col. Philadelphia : 
Lindsay & Blakiston, 1861. (From the Publishers.) 

Microscopic Anatomy of the Lumbar Enlargement of the Spinal Cord. By 
John Dean, M.D. Communicated to the American Academy of Arts and Sci- 
ences by Prof. Jeffries Wyman, Nov. 16, 1860. Cambridge, 1861. (From the 
Author.) 

A Paper on Diphtheria. Read before the New York Acad. Med., Jan. 1861. 
By James Wynne, M. D. New York, 1861. 

Proceedings of the Academy of Natural Sciences of Philadelphia, March, 
April, 1861. 

Extracts from the Records of the Boston Society for Medical Improvement. 
By Francis Minot, M. D., Secretary of the Society. Yol. IY., No. 3. Boston, 

1861. (From the Secretary.) 

Medical Communications, with the Proceedings of the Sixty-ninth Annual 
Convention of the Connecticut Medical Society, held at New Haven, May 22 
and 23, 1861. Hartford, 1861. 

Report of Professor Yalentine Mott's Surgical Cliniques in the University of 
New York, Session 1859-60. By Samuel W. Francis, Member of Dr. Mott's 
Surgical Staff. New York : S. S. & W. Wood, 1860. 

A Book about Doctors. By J. Cordy Jeaffres.on. Reprinted from the Eng- 
lish edition. New York: Rudd & Carleton, 1861. (From the Publishers.) 

Biographical Sketches of Deceased Physicians of Westchester County, New 
York ; being the Annual Address before the Westchester County Med. Society, 
June, 1858. By Geo. J. Fisher, M. D. New York, 1861. (From the Author.) 



8 



TO READERS AND CORRESPONDENTS. 



Eeport on Morbus Coxarius or Hip-Disease. By Lewis A. Sayre, M. D. 
From Trans. Am. Med. Ass. Phil. 1861. (From the Author.) 

Our Alma Mater Fifty Years Ago. An Oration delivered before the Alumni 
Association of the Coll. Phys. and Surg. N. Y., March 14, 1861. By Thomas 
W. Blatchford, M. D. Troy, N. Y. 1861. (From the Author.) 

The Modus Operandi of various kinds of Baths physiologically explained. 
By John O'Reilly, M. D. New York, 1861. (From the Author.) 

The Physician's Pocket Dose and Symptom Book ; containing the doses and 
uses of all the principal articles of the Materia Medica, &c. &c. By Joseph H. 
Wythes, M. D. Third edition. Philadelphia, 1861. (From the Publishers.) 

Fortieth Annual Report of the Surgeons of the New York Eye Infirmary, 
Second Avenue, corner of Thirteenth Street, for the year 1860. Founded 1820. 
New York, 1860. 

Report of the Board of Commissioners and of the Superintendents of the 
Provincial Lunatic Asylum of New Brunswick for the year 1860. St. John's, 
N. B., 1861. (From John Waddell, M. D., Medical Superintendent.) 

Tenth Annual Report of the New York Asylum for Idiots. Transmitted to 
the Legislature Jan. 25, 1861. Albany, 1861. 

First Annual Report of the Superintendent of Clifton Hall, a private Hospital 
for the Insane, to the Board of Supervision, for the year 1860. Philadelphia, 
1861. (From Dr. R. A. Given.) 

Address to the Graduates of the Medical Department of Pennsylvania Col- 
lege. By B. Howard Rand, M. D., Prof, of Chemistry. Philadelphia, 1861. 
(From the Author.) 

Third Report of the Legislature of Yermont, relating to the Registry and 
Returns of Births, Marriages, and Deaths, in the State, for the year ending 
Dec. 3L, 1859. Prepared under the direction of Benjamin W. Dean, Secretary 
of State. Middlebury, 1860. (From H. F. Stevens, M. D.) 

Sixth Annual Report on the Births, Marriages, and Deaths in the City of 
Providence, for the year 1860. With a Recapitulation of the Yital Statistics 
of the City for the last five years, &c. By Edwin M. Snow, M. D., Superin- 
tendent of Health, and City Registrar. Providence, 1861. (From the Author.) 

Report of the Board of Managers of the Lunatic Asylum of the State of 
Missouri to the Twenty-first General Assembly. Jefferson City, Mo., 1861. 
(From Dr. T. R. H. Smith.) 

Provincial Hospital for the Insane, Halifax, Nova Scotia. Third Report of 
the Medical Superintendent. Halifax, N. S., 1861. (From Dr. J. R. De Wolf.) 

Forty-fourth Annual Report on the State of the Asylum for the Relief of 
Persons deprived of the Use of their Reason. Published by direction of the 
Contributors. Philadelphia, 1861. (From Dr. J. H. Worthington.) 

Report of the Board of Managers of the Pennsylvania Hospital to the Con- 
tributors at their Annual Meeting, 5th month, 1861. Philadelphia, 1861. 

Fifth Annual Report of the Board of Managers of the Children's Hospital of 
Philadelphia, 1861. 

Report of State Hospital Committee on State Insane Asylum at Stockton, 
California. 

An Address delivered at the Annual Commencement of the Medical School 
of Harvard University, Wednesday, March 6, 1861. By George C. Shattuck, 
M. D., Hersey Prof. Theory and Pract. Med. Boston, 1861. (From the Author.) 

Catalogue of the Trustees, Officers, and Students of the University of Penn- 
sylvania, Session 1860-61. Philadelphia, 1861. 

Circular of the Medical Institution of Yale College, Session 1861-2. New 
Haven, Conn., May 1, 1861. 

Fifty-fourth Annual Circular of the University of Maryland, School of Medi 
cine, Session 1861-2. Baltimore, 1861. 

Annual Catalogue and Announcement of the St. Louis Medical College, Ses- 
sion 1861-2. St. Louis, 1861,. 



TO READERS AND CORRESPONDENTS. 



9 



The following Journals have been received in exchange : — 
Gazette Medicale de Paris. March, April, 1861. 

Journal de Medecine de Bordeaux. Eedacteur en chef, M. Costes. Jan., 
Feb., March, April, 1861. 

Le Moniteur des Sciences M6dicales et Pharmaceutics. Eedacteur en chef, 
M. H. De Castelneau. March, April, May, 1861. 

Annales Medico-Psychologiques. Par MM. les Docteurs Baillarger, Cerise, 
et Moreau (de Tours). April, 1861. 

The British and Foreign Medico-Chirurgical Eeview. April, 1861. 

The Medical Critic and Psychological Journal. Edited bv Forbes Winslow, 
M. D. April, 1861. 

Ophthalmic Hospital Eeports and Journal of the Eoyal Ophthalmic Hospital. 
Edited by J. F. Streatfeild. Nos. 13 and 14. 

Edinburgh Medical Journal. February, March, April, May, June, 1861. 

London Medical Eeview. March, April, May, 1861. 

British Medical Journal. March, April, May, 1861. 

Dublin Medical Press. March, April, May, 1861. 

Medical Times and Gazette. April, May, June, 1861. 

The Dublin Quarterly Journal of Medical Science. May, 1861. 

Edinburgh Veterinary Eeview, May, 1861. 

The British American Journal. Edited by Archibald Hall, M. D. April, 
May, 1861. 

The Boston Medical and Surgical Journal. Edited by F. E. Oliver, M. D., 
and S. L. Abbot, M. D. April, May, June, 1861. 
American Medical Times. April, May, June, 1861. 

The Maryland and Virginia Medical Journal. Edited by J. B. McCaw, M.D., 
W. C. Van Bibber, M. D., and W. A. Hammond, M.D. April, May, 1861. 

The North American Medical and Surgical Journal. Edited by Drs. S. D. 
Gross, T. G. Eichardson, and S. W. Gross. May, 1861. 

Southern Medical and Surgical Journal. Edited by H. F. Campbell, M. D., 
and E. Campbell, M. D. March, April, 1861. 

The Cincinnati Lancet and Observer. Edited by Drs. Stevens, Murphy, 
and Weber. April, May, June,1861. 

The Berkshire Medical Journal. Edited by Wm. H. Thayer, M. D., and E. 
C. Stiles, M. D. February, March, April, May, 1861. 

The American Journal of Insanity. Edited by the Medical Officers of the 
New York State Lunatic Asylum. April, 1861. 

The New Orleans Medical and Surgical Journal. Edited by Bennet Dowler, 
M.D. May, 1861. 

The New Orleans Medical Times. Edited by A. Peniston, M.D. April, 
May, 1861. 

The American Journal of Science and Arts. Edited by Profs. B. Silliman, 
B. Silliman, Jr., and J. D. Dana. May, 1861. 

The Chicago Medical Journal. Edited by D. Brainard, M. D., and J. A. 
Allen, M. D. March, April, 1861. 

The Savannah Journal of Medicine. Edited by Drs. Harriss, Arnold, and 
Wilson. April, 1861. 

The Chicago Medical Examiner. Edited by N. S. Davis, M. D. March, 
June, 1861. 

Atlanta Medical and Surgical Journal. Edited by J. G. Westmoreland, 
M. D. April, May, 1861. 

The Pacific Medical and Surgical Journal. Edited by David Wooster, M. D. 
March, April, May, 1861. 

Baltimore Journal of Medicine. Edited by E. Warren, M. D. May, 1861. 

Cleveland Medical Gazette. Edited by G. C. E. Weber, M. D., E. B. Ste- 
vens, M. D., and J. A. Murphy, M. D. May, June, 1861. 

Summary of Medical Science. Edited by W. K. Wells, M. D. April, 1861. 

The Cincinnati Medical and Surgical News. Edited by A. H. Baker, M. D., 
and J. A. Thacker, M. D. March, April, May, 1861. 

American Medical Gazette. Edited by D. M. Eeese, M. D. April, 1861. 



10 



TO READERS AND CORRESPONDENTS. 



Nashville Journal of Medicine and Surgery. Edited by W. K. Bowlixg, 
M. D. April, 1861. 

St. Louis Medical and Surgical Journal, Edited by M. L. Lixtox, M. D., 
and W. M. McPheeteks, M. D. May, 1861. 

The Medical Journal of North Carolina. Edited by C. E. Johxsox, M. D., 
and S. S. Satchwell, M. D. May, 1861. 

American Medical Monthly. Edited by J. H. Douglas, M. D. May, June, 
1861. 

The Pacific Medical and Surgical Journal. Edited by David Wooster, M. D. 
February, 1861. 

Ohio Medical and Surgical Journal. Edited by Johx Dawsox, M. D., and 
J. W. Hamiltox, M. D. May, 1861 . 

The American Journal of Pharmacy. Published by authority of the Phila- 
delphia College of Phvsicians. Edited by Wm. Procter, Jr., Prof. Pharmacy, 
Phil. Coll. Pharm. March, May, 1861. 

The American Druggists' Circular and Chemical Gazette. April, May, June, 
1861. 

The Druggist. May, June, 1861. 

The Dental Cosmos. Edited by J. D. White, M. D., J. H. McQuillex, 
D. D. S., and Geo. J. Ziegler, M. D. April, May, 1861. 

The New York Dental Journal. Edited by W. B. Koberts and F. H. Nor- 
tox. April, 1861. 

The Dental Register of the "West. Edited by J. Taft and Geo. Watt. 
May, 1861. 



Communications intended for publication, and Books for Review, should be sent, 
free of expense, directed to Isaac Hays, M. D., Editor of the American Journal of the 
Medical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed 
as above, and (carriage paid) under cover, to Messrs. Triibner & Co., Booksellers, 
No. 60 Paternoster Row, London, E. C. ; or M. Hector Bossange, Lib. quai Voltaire, 
No. 11, Paris, will reach us safely and without delay. We particularly request 
the attention of our foreign correspondents to the above, as we are often subjected 
to unnecessary expense for postage and carriage. 

Private communications to the Editor may be addressed to his residence, 1525 
Locust Street. 

All remittances of money, and letters on the business of the Journal, should be 
addressed exclusively to the publishers, Messrs. Blanchard & Lea. 

The advertisement-sheet belongs to the business department of the Journal, 
and all communications for it should be made to the publishers. 

To secure insertion, all advertisements should be received by the 20th of the 
previous month. 



CONTENTS 



OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

NO. LXXXIII. NEW SERIES. 
JULY, 1861. 



ORIGINAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE 

I. On Dislocations of the Shoulder-Joint, with a Description of a Novel 
and Efficient Method of Reduction. By N. R. Smith, M. D., Professor 

of Surgery in the University of Maryland. (With a wood-cut.) . . 17 

II. Statistical Inquiry as to the Expediency of Excision of the Head of the 
Femur. By Charles K. Winne, M. D., of Buffalo, N. Y. . . .26 

III. Notes of Surgical Cases. By B. A. Clements, M. D., Assistant Sur- 
geon U. S. Army . . .37 

IY. Experiments to determine the Effect on the System of the Asclepias 
Syriaca. By Christopher James Cleborne, M. D., Assistant Surgeon U. 
S. Navy. . . . ... . . ' 46 

Y. On the Antagonistic Effects of Opium and Sulphate of Quinia. By 
Nelson Nivison, M. D., of Hector, Schuyler County, N. Y. . . .51 

YI. Three Cases of Yesico-Yaginal Fistula, successfully treated by Sims' 
Method. By J. Mercer Adler, M. D., of Davenport, Iowa. (With five 
wood-cuts.) 58 

YII. Spina Bifida, treated by Iodine; Cure by one Injection. By Daniel 
Brainard, M. D., Professor of Surgery in Rush Medical College, etc. . 65 



TRANSACTIONS OF SOCIETIES. 

YIII. Summary of the Transactions of the College of Physicians of Phi- 
ladelphia. .69 

Report on Meteorology and Epidemics for 1860. By Dr. W. Jewell. 69 

FISKE FUND PRIZE ESSAY. 

IX. On "The Morbid Effects of the Retention in the Blood of the Elements 
of the Urinary Secretion." By Wm. W. Morland, M. D. 101 



REYIEWS. 

X. A Practical Treatise on Phthisis Pulmonalis; embracing its Pathology, 
Causes, Symptoms, and Treatment. By L. M. Lawson, M. D., Prof, of 
Clinical Medicine in the University of Louisiana, &c. Cincinnati, 1861. 
8vo. pp. 557. 



12 



CONTENTS. 



The Forms, Complications, Causes, Prevention, and Treatment of Consump- 
tion and Bronchitis : comprising also the Causes and Prevention of Scro- 
fula. By James Copland, M.D., F.E. S., &c. London, 1861. 8vo. pp. 440. 

Lecons Cliniques sur les Causes et sur le Traitement de la Tuberculisation 
Pulmonaire, faites a l'Hotel Dieu (1859). Par Noel Gueneau de Mussy. 
Paris, 1860. 8vo. pp. 134. 

The Physical Examination of the Chest in Pulmonary Consumption and its 
Intercurrent Diseases. By Somerville Scott Alison, M. D. London, 1861. 
8vo. pp. 447 137 

XI. Sanitary Science. 

1. Proceedings and Debates of the Fourth National Quarantine and San- 
itary Convention, held in the city of Boston, June 14, 15, and 16, 1860. 
Eeported for the City Council of Boston. Geo. C. Band and Avery, 
City Printers. Boston, 1860. 

2. Public Health. The Eight Use of Eecords founded on Local Facts; 
being two papers read before the National Association for the Promo- 
tion of Social Science, at Bradford, in October, 1859; with an account 
of subsequent proceedings. By Henry Wyldbore Eumsey, Author of 
"Health and Sickness of Town Populations," " Essays on State Medi- 
cine," &c. London, 1860. . " . 181 

XII. A Treatise on Fever: or Selections from a Course of Lectures on Fe- 
ver. Being part of a Course on the Theory and Practice of Medicine 
delivered by Eobert D. Lyons, K. C. C, M. B. T. C. D., L. K. Q. C. P. I., 
L. E. C. S. I., M. E. I. A., Physician to Jervis-Street Hospital; formerly 
Clinical Assistant to the Meath Hospital; Professor of Practice of Med- 
icine and Pathology in the School of Medicine of the Catholic University 
of Ireland; Foreign Secretary to the Pathological Society of Dublin; 
M. E. M. S. Lisbon. Late Pathologist-in-Chief to the British Army in 
the Crimea, etc. etc. Philadelphia: Blanchard & Lea, 1861. 8vo. pp. 



362 194 

XIII. A Manual of Human Microscopic Anatomy. By A. Kolliker, Prof, 
of Anat. and Physiol, in the Univ. of Wiirzburg. With 249 illustrations. 
London: J. W. Parker & Son, 1860 207 



BIBLIO GEAPHIC AL NOTICES. 

XIY. Hand-book for the Military Surgeon : Being a Compendium of the 
Duties of the Medical Officer in the Field, the Sanitary Management of 
the Camp, the Preparation of Food, etc ; with Forms for the Eequisi- 
tions for Supplies, Eations, etc.; the Diagnosis and Treatment of Camp 
Dysentery ; and all the Important Points in War Surgery : including 
Gunshot Wounds, Amputation, Wounds of the Chest, Abdomen, Arteries, 
and Head, and the Use of Chloroform. By Chas. S. Tripler, M. D., Sur- 
geon United States Army. And George C. Blackman, M.D.F. E.M. S., 
Prof, of Surgery in the Med. Coll. of Ohio, &c. &c. Cincinnati: Eobert 
Clarke & Co., 1861. 12mo. pp. 163, including Appendix of Forms. 

A Manual of Military Surgery; or Hints on the Emergencies of Field, 
Camp, and Hospital Practice. Illustrated with Wood Cuts. By S. D. 
Gross, M.D., Prof, of Surg, in the Jefferson Med. Coll. of Phila. Phila- 
delphia : J. B. Lippincott & Co., 1861. 24mo. pp. 186. 

A Practical Treatise on Military Surgery. By Frank Hastings Hamilton, 
M.D., Late Surgeon 33d Eeg. 4th Brigade 4th Div. N. Y. S. Artillery; 
Prof, of Military Surgery, &c. &c. New York : Bailliere Brothers, 1861. 
8vo. pp. 234, including Appendix and Index, with several wood-cuts. . 213 

XY. Another Letter to a Young Physician : to which are appended some 
other Medical Papers. By James Jackson, M. D., &c. 12mo., Boston. 
1861 218 



CONTENTS. 



13 



ART. PAGH 

XVI. Eeports of American Institutions for the Insane. 

1. Of the State Hospital of Pennsylvania, for the year 1860. 

2. Of the Western Pennsylvania Hospital, for the year 1860. 

3. Of the Mt. Hope Institution, for the year 1860. 

4. Of the Eastern Kentucky Asylum, for the fiscal year 1859-60. 

5. Of the Central Ohio Asylum, for the fiscal year 1859-60. 

6. Of the Southern Ohio Asylum, for the fiscal year 1859-60. 

7. Of the Indiana Hospital, for the fiscal year 1859-60. 

8. Of the Illinois State Hospital, for the fiscal years 1858-59 and 1859-60. 220 

XVII. Microscopic Anatomy of the Lumbar Enlargement of the Spinal 
Cord. By J. Dean, M. D., communicated to the Amer. Acad, of Arts 
and Sciences, by Prof. J. Wyman, Nov. 14, i860. . Cambridge, 1861 : 

pp. 21, quarto, with 4 plates. . . 227 

XVIII. Researches upon the Venom of the Kattlesnake ; with an Investi- 
gation of the Anatomy and Physiology of the Organs Concerned. By S. 
Weir Mitchell, M.D., Lecturer on Physiology in the Philadelphia Medi- 
cal Association. Published by the Smithsonian Institution, Jan., 1861. 
Pp. 145. With twelve wood-cuts. . .... , 229 

XIX. A Treatise on the Practice of Medicine. By Edwin R. Maxon, M. D., 
formerly Lecturer on Institutes and Practice of Medicine in the Geneva 
Medical College. 8vo. pp. 705. Philadelphia : Lindsay & Blakiston, 
1861 . . . . . . * .231 

XX. Report of Professor Valentine Mott's Surgical Cliniques in the Uni- 
versity of New York, Session 1859-60. By Samuel W. Francis, Member 

of Dr. Mott's Surgical Staff. S. S. & W. Wood, 1860 : 12mo. pp. 204. . 232 

XXI. Guy's Hospital Reports. Edited by Samuel Wilks, M.D., and Alfred 
Poland. Third Series, Vol. VI. London : 1860. 8vo. pp. 531. . . 232 

XXII. Cours Theorique et Clinique de Pathologie Interne et de Therapie 
Medicale, par E. Gintrac, Professeur de Clinique Interne et Directeur de 
l'Ecole de Medecine de Bordeaux, Membre de la Commission Adminis- 
trative des Hospices Civils, etc. etc. Tomes 4e et 5e, 8vo. pp. 750, 821. 
Paris, 1859. 

A Theoretical and Clinical Course of Internal Pathology and Medical 
Therapeutics. By E. Gintrac, Professor of Internal Clinic, Director of 
the School of Medicine of Bordeaux, Member of the Administrative Com- 
mission of the Civil Hospitals, etc. etc. Vols. IV. and V. 242 

XXIII. Infant Feeding and its Influence on Life ; or the Causes and Pre- 
vention of Infant Mortality. By C. H. F. Routh, M. D., M. R. C. P. E„ 
M. R. 0. S., Physician to the Samaritan Free Hospital for Women and 
Children, etc. etc. 12mo. pp. 379. London : 1860 249 

XXIV. On the Signs and Diseases of Pregnancy. By Thomas Hawkes 
Tanner, M. D., F. L. S., Member of the Royal College of Physicians, etc. 
etc. 12mo. pp. 504. London, 1860 256 

XXV. Relatorio do Gabinete Estatistico Medico-Chirurgico do Hospital 
Geral da Santa Casa da Misericordia e Enfermarias publicas, Apresentado 
Ao Exmo. Sr. Marquez D'Abrantes, Provedor da Santa Casa, pelo Dr. 
Luiz Da Silva Brandao, Director do Gabinete Estatistico, etc. etc. Rio 
De Janeiro, 1860, 4to. pp. 62. 

Report of the Department of Medico-Chirurgical Statistics of the General 
Hospital Santa Casa da Misericordia, and of the Public Infirmaries, etc. : 
by Dr. Luiz Da Silva Brandao, Director of the Department of Statistics, 
etc. 257 



14 



CONTENTS. 



QUAETEELY SUMMAEY 

OF THE 

IMPROVEMENTS AXD DISCOVERIES IN THE 
MEDICAL SCIENCES. 

FOREIGN INTELLIGENCE. 
Anatomy and Physiology. 



PAGE PAGE 

1. On the Physiology of the Valves 2. Physiology of the Thymus 



of the Heart. By Ludwig J o- 
seph. . 259 



Gland. By Friedleben. 



. 259 



Mateeia Medica axd Phaejiacy. 



3. Administration of Medicines. 1 7. Method of making Endermic 

By Dr. Henry Kennedy. . .260! Applications. By M. Trousseau. 261 

4. Use of Glycerine in the Internal 8. Distilled Water of Copaiba. By 

Employment of Chloroform. By ! E. Langlebert 261 

M. Bonnet 260 . 9. Chlorate of Potash and Glyce- 

5. Action of Chloroform. By Dr. \ rine as a Topical Disinfectant. 
Sansom 261 1 By M. Martinet. . . .261 

6. Celandine as a Vulnerary. By 

Dr. Sacc 261 1 



Medical Pathology axd Therapeutics, axd Practical Medicixe. 



10. Hypophosphites in the Treat- 
ment of Phthisis. By Dr. James 
Risdon Bennett. . . .262 

11. Action of Liquor Potassse upon 
Phthisis. By Dr. R, P. Cotton. 263 

12. Influence of Ozonized Cod- 
liver Oil on the Pulse. By Dr. 

E. Symes Thompson. . . 261 

13. Acetate of Lead in Pneumonia. 

By Prof. Strohl. . . .265 

14. Arseniate of Soda in Scrofula. 

By Dr. Bouchut, . . . 265 

15. The Grape Cure. By Dr. Aran. 266 

16. Typhoid Fever and its Treat- 
ment. By Prof. Pfeufer. . . 267 

17. Researches on Asphyxia ; with 
Observations on the Effects pro- 



duced by the Hot Bath in As- 
phyxiated Animals, and its Use- 
in Restorino- Suspended Anima- 
tion. . By Dr. A. T. H. Waters. 268 

18. Cerebral Circulation in As- 
phyxia. By Prof. Ackerman. . 270 

19. Diabetes resulting from Dis- 
ease of the Floor of the Fourth 
Ventricle 270 

20. Quinine in Scarlatinal Dropsy. 

By Dr. Hamburger. . . .270 

21. Two Ounces of the TTine of 
the Seeds of Colchicum acci- 
dentally taken by a Gouty Sub- 
ject with Relief. By Dr. Joseph 
Bullar. . . . .271 



CONTENTS. 



15 



Surgical Pathology and Therapeutics, and Operative Surgery. 



PAGE 

22. Statistics of Amputation. By 
G-. F. Cooper and T. Holmes, 
Esq 271 

23. Excision of the Tendons in 
Amputation of the Forearm at 
the Lower Third. By Mr. Hugh 
Croskery 274 

24. Extirpation of the Shaft of the 
Tibia. Complete Eecovery. . 275 

25. On the Growth of Long Bones 
and of Stumps. By Dr. Hum- 
phrey 276 

26. Mode of Union of Fractures. 

By Mr. Lawson. . . . 277 

27. Removal of a Ball by means of 
the Trephine twenty-two months 
after its Penetration into the 
Cranium. By M. Jobert. . . 277 



PAGE 

28. Gunshot Wounds produced du- 
ring the Loading of Artillery. 

By Dr. Cortese. . . .278 

29. Traumatic Tetanus. By Mr. 
J. Hutchinson and Dr. J. H. 
Jackson 278 

30. Eadical Cure of Reducible 
Hernia, By Prof. Syme. . . 279 

31. Abdominal or Pelvic Abscess. 

By F. C. Skey, Esq. . . .279 

32. Pulsating Bronchocele. By 
Dr. J. Bullar 281 

33. Communication of Secondary 
Syphilis 282 

34. On Affection of the Mucous 
Follicles of the Urethra in Gon- 
orrhoea. By M. Diday. . . 282 



Ophthalmology. 



35. Impairments of Yision caused 
bv Lactation. By Mr. George 
Lawson 283 

36. Hypertrophy of the Connec- 



tive Tissue of the Optic Nerve in 
Relation to Albuminuric Amau- 
rosis. By Prof. Malmsten and 
Dr. Gyllenschjold. . . .286 



Midwifery. 



37. Treatment of Cases of Abor- 
tion in which the Membranes 
and Placenta are retained. By 
Dr. W. 0. Priestley. . . 286 

38. On the Length and Weight of 
New-born Infants. By Dr. E. 
von Siebold 288 

39. Placenta Praevia, Podalic Ver- 
sion. By Dr. D. L. Roberts. . 289 



40. Placenta Prsevia. By Glis- 
czynski 290 

41. On Serous Discharges during 
Pregnancy. By M. Danyau. . 290 

42. Ascites complicating Pregnan- 



cy- 



290 



43. Glycerine and Tannin in the 
Treatment of Yaginitis and Leu- 
corrhcea 290 



AMERICAN INTELLIGENCE. 

Original Communications. 



Peritonitis from Perforation of the 
Appendix Vermiformis, result- 
ing in Gangrene. By Frederic 
D. Lente, M. D. . . .291 

Case of Gunshot Wound in which 
a Leaden Bullet remained twenty 
Years in the Walls of the Heart. 
By Galusha B. Balch, M. D. . 293 

Diagnosis of Traumatic Tetanus. 
By H. A. Jones, M. D. . . 294 

Case of Poisoning by Corrosive 
Sublimate. By J. L. Ord, M. D. 294 



Remarkable Case of Trance. By 
W. Turk, M.D. . . .295 

Note to a Report of a Case of 
Destruction of a Solid Ovarian 
Tumour by Incision followed, by 
Suppuration. By D. Prince, 
M.D 296 

Sequel to the Case of Extirpation 
of the Parotid Gland. Reported 
in this Journal for July, 1860, 
page 57. By D. Prince. . . 297 



16 



CONTENTS. 



Domestic Summary. 



page 

New Method of Treating Fractures 
of the Femur. By Dr. Gurdon 
Buck .297 

Complete Osseous Anchylosis of 
the Knee-Joint. Successfully 
Operated on by Barton's Me- 
thod. By Dr. Chas. A. Pope. . 298 

Surgical Treatment of Epilepsy. 
By Dr. J. S. Billings. . . 299 

Castration for Epilepsy. By Dr. 
L. Booker 300 

Ligature of the Primitive Carotid 



PAGE 

Artery for Wound of the Inter- 
nal Maxillary Artery ; Recovery. 
By Dr. J. C. Hutchinson. . 300 

Coffee as a Bemedy for Hooping- 

Cough 301 

i Confluent Smallpox in a Pregnant 
Woman — Child Marked. By Dr. 
W. C. Corson 301 

Absence of the Uterus in Three 
Sisters in a Family of Five. By 
Dr. E. Nelson 301 



THE 

AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR JULY 18 6 1. 



Art. T. — On Dislocations of the Shoulder-Joint, with a Description of a 
Novel and Efficient Method of Reduction. By N. R Smith, M. D., 
Professor of Surgery in the University of Maryland. (With a wood-cut.) 

The anatomical mechanism of the shoulder-joint has remarkable pecu- 
liarities. Although classed with ball-and-socket articulations, it can scarcely 
be said to possess a socket at all, though having a very perfect head. So 
far as the bones are concerned, it is very imperfectly fortified, being re- 
markably contrasted in this respect with the hip-joint. 

The shoulder-joint is also destitute of proper ligaments, that which is 
termed the capsular, or orbicular ligament, being little else than a loose 
synovial capsule, fortified with but few fibrous threads. The extreme 
mobility of this joint precludes the use of close ligaments, and also deep 
interlocking of the bones. Nature must therefore resort to adventitious 
mechanical aids to render secure this important joint. 

The extreme mobility of the scapula would, at first thought, seem to be 
a circumstance of insecurity. It is, however, really quite the reverse, the 
ready yielding of the scapula defeating the effect of violence exerted on the 
joint through the humerus. The facile motions of the scapula, effected by 
its complicated muscular apparatus, enable it to present its shallow glenoid 
in almost every direction. When the arm is elevated, and sustains a force 
from above, the glenoid looks upward to oppose it. When we fall upon 
the hand, laterally, the same cavity presents downward and outward. It 
is thus capable of almost instantly opposing its surface to the head of the 
humerus, in whatever attitude it may present itself ; thus revolving around 
it and really, in its mechanism, representing a much deeper cup than that 
which it exhibits in the skeleton. 

Although this joint is destitute of a fibrous capsule, it possesses a substi- 
JSTo. LXXXIIL— July 1861. 2 



18 Smith, Dislocations of the Shoulder-Joint. [July 

tute wonderfully adapted to its necessities. It has a most effective mus- 
cular capsule. Four powerful muscles arising from the scapula embrace 
the head, and are inserted into its base, the two bicipital tuberosities. 

These muscles are far less concerned in the various motions of the joint 
than in keeping the head of the bone, in all its movements, closely applied 
to the glenoid cup. They perform, indeed, the office of a powerful con- 
tractile capsular ligament. If it were a fibrous resistant capsule, it would 
be either too loose to support the joint, or so close as to check its useful 
movements. These muscles are always in action when the extremity is 
being exercised. 

The coracoid and acromial processes, with the coraco-acromial ligament, 
also adventitiously fortify the joint above, and in the direction in which 
the head of the bone is most frequently impelled. The tendon of the 
biceps, passing over the head of the bone, supports the joint in that 
direction in no small degree. Its continuity with the muscle gives it the 
character of an elastic and contractile ligament. 

Notwithstanding these mechanical advantages peculiar to this joint, it is, 
owing to its great variety and extent of motion and the powerful leverage 
of the humerus, more frequently dislocated than any other articulation. 

The various dislocations of the humerus illustrate more clearly than 
those of any other joint, the mechanism of the muscles in the production 
of luxation. This we should infer from the important part they perform 
in the offices of the joint. 

The part which accidental violence performs in dislocating the shoulder 
is simply distortion. A person in falling, for instance, has the arm vio- 
lently abducted — thrown upward against the side of the head. The thin 
capsule is strained and ruptured below ; the muscular capsule, which em- 
braces the head of the bone above, and which should resist dislocation, is 
relaxed ; so also the deltoid. But there are three very powerful muscles 
which are violently put upon the stretch — the latissimus dorsi, the teres 
major, and the pectoralis major. By the action of these muscles the head 
of the bone is drawn violently into the axilla. The action of these mus- 
cles at the moment is abnormally violent, because, by the sudden force in- 
flicted upon them, they are provoked to spasmodic action. 

That such is the mechanism of this displacement is manifest from the 
fact that it is often effected by muscular action alone. It is not an un- 
common occurrence for the humerus to be dislocated in a paroxysm of 
epilepsy. Many years ago I knew a lady subject to this malady, who 
suffered dislocation of the shoulder in almost every paroxysm. In the 
practice of my father, the late Prof, of Surgery in Yale College, a case 
occurred in which, in a paroxysm of puerperal convulsions, both shoulders 
were simultaneously disolcated and remained displaced for a long period of 
time, owing to the nature of the lesion being unnoticed at the time of its 
occurrence. In these cases the deltoid violently effects the abduction of the 



1861.] 



Smith, Dislocations of the Shoulder- Joint. 



19 



arm, while the pectoral and latissimus, with equal and sudden force, jerk 
the head downward into the axilla. This is the result of the want of har- 
mony in the action of the muscles in the abnormal state. 

The parts which suffer lesion in displacement are those, of course, which 
resist dislocation. The most important of these are the four muscles in- 
serted into the bicipital tuberosities. Their fibres are, some of them, very 
short, and suffer laceration in vainly resisting. 

The dislocation of the humerus forward under the coracoid is generally 
consecutive in relation to the axillary displacement. The head is first 
forced into the axilla, and then, sometimes the pectoral muscle being more 
stretched than the latissimus by the humerus being driven backwards as 
well as outwards, is dragged forward under the coracoid. In other cases 
it is effected by the inflicting of a blow upon the elbow, transmitting the 
force in the direction of the length of the humerus, the head of the bone 
being presented forward at the moment of the distortion. 

The backward displacement of the head of the humerus, on the dorsum 
of the scapula, under the spine of this bone, is rare. I have seen but three 
cases in an extensive surgical practice of forty years. Only one of these 
was recent. Such displacement is probably effected by the combined action 
of two forces. A person falls forward with violence, the elbow encounters 
the ground, which inflicts a forcible counter-stroke in the direction of the 
length of the humerus. The arm at the same moment is driven forward 
upon the breast, rendering tense the latissimus dorsi, the teres major, and 
the posterior border of the deltoid. Provoked to spasmodic action, they 
co-operate with the counter-stroke in forcing the head over the border of 
the glenoid, backward. 

It is not my purpose in this article to discuss fully the diagnosis of in- 
juries of the shoulder, but rather to describe a method in some respects 
peculiar to myself (as I believe) of effecting the reduction of the luxated 
humerus. 

I will remark, however, that I have known dislocation of the scapular 
end of the clavicle to be mistaken for dislocation of the head of the humerus 
— also fracture of the neck of the scapula, and fracture of the neck of the 
humerus — to be taken for the same injury. I have even known dislocation 
to be mistaken for a fracture of the humerus at the insertion of the deltoid, 
owing to the remarkable angle which the deltoid makes with the shaft of 
the bone at that point, when the head is displaced deeply in the axilla. 

The mechanism of the reduction of a dislocated bone is, in most respects, 
similar to that of the dislocation. As muscular force is concerned in the 
displacement, so is it in the reduction. Accidental violence has been known 
to reduce a joint dislocated by the same. In Sir Astley Cooper's work on 
Fractures and Dislocations is related a case in which the hip-joint, dis- 
located years before on the dorsum ilii, was reduced accidentally by violence 
received by a fall in a storm at sea. 



20 Smith, Dislocations of the Shoulder-Joint. [July 

The force employed generally requires to be the converse of that which 
effected the displacement. Thus, if violent abduction has luxated a mem- 
ber, the opposite movement, or adduction, should effect its replacement, 
aided by the action of a set of muscles the antagonists of those which were 
concerned in the displacement. Traction, or extension, is, however, a part 
of the mechanism of reduction, but not often, if ever, of dislocation. This 
is a consequence of the overlapping of the bones and shortening of the 
limb in dislocations. The limb must, in many cases, be elongated in the 
mechanism of reduction, but not generally so in dislocations. 

By far the most common dislocation of the shoulder is that into the 
axilla. It is not my purpose to give the history of the art of reduction as 
practised by various surgeons, but merely to describe the method which I 
have for many years practised and found to be the most efficient. 

Extension, counter-extension, and manipulation, constitute the mechan- 
ism of the operation of reduction. Counter-extension is the mere fixing, 
or rendering firm and immovable, the scapula. The head of the humerus 
alone requires to be relatively moved. The immobility of the scapula 
effected by counter-extension, is obviously of essential importance. All the 
movements of the head of the bone, effected in the effort to reduce the same, 
would merely drag or thrust the scapula loosely about, without changing 
the relative positions of the head and glenoid. 

To effect the immobility of the scapula is the real difficulty in the reduc- 
tion of this dislocation. In many of the methods practised, the bands 
employed for this purpose oppose the return of the head of the bone to its 
place. By some a slit is made in a broad band of stout muslin, the arm 
carried through it, and one margin of the slit brought into the axilla and 
the other against the acromion. The tails of the band are carried, one 
across the breast, the other across the back, horizontally, and are secured 
to the wall. The lower margin of the slit supports effectually the lower 
portion of the scapula, but the support of the upper, which is by far the 
most important, is not well effected. The margin of the band cannot be 
expected to remain opposed to the thin edge of the acromion. It will either 
glide over the top of it, or fall beneath it into the depression caused by the 
dislocation. In the former case it will not support the scapula above, but 
will allow it to be drawn outward and downward. In the latter case it 
will, by occupying the cavity to which the head of the bone is to be re- 
turned, hinder the reduction. 

In effecting counter-extension, it is undoubtedly, in most instances, expe- 
dient to apply our resisting bands as directly as possible to the bone from 
which the other is dislocated. But the difficulty in this case is to effect it 
without defeating the object in the manner indicated above. 

On noticing the mechanical relations of the scapulae, with their appa- 
ratus of muscles, to each other, it occurred to me to make counter-exten- 
sion from the opposite wrist, an expedient directly at variance with the 



1861.] 



Smith, Dislocations of the Shoulder- Joint. 



21 



commonly received principle, because as remotely as possible from the bone 
to be supported. There are exceptions to most rules, and I shall endeavour 
to establish this as one. 

Let us observe the continuity of ligament, bone, and tendon by which 
the two scapulas are bound together and made mechanically dependent 
upon each other. Anteriorly the two acromion processes are bound to- 
gether by an unyielding chain of bone and ligament. The two clavicles, 
the sternum, and the interclavicular ligament chiefly constitute this bond 
of union. The fibrous-resistent ligaments in this chain are not capable of 
being stretched. If traction be made from opposite wrists, the two acro- 
mion processes, thus tied together, are not capable of being drawn asunder 
to the extent of half an inch. 

Posteriorly the continuity of resisting parts is almost as perfect. The 
broad expansions of the scapula? approach each other not remotely, and they 
are bound to each other by the interposition of the ligamentum nuchas, and 
indirectly by muscles and tendons attached to the spine. Traction from 
the two extremities will not therefore separate the scapulas to any consider- 
able extent. 

The superior angles of the scapulas indirectly support each other through 
the medium of the cervical portion of the spine. The levator muscles, 
arising from the superior angles of the scapulas, pass upward to be inserted 
into the transverse processes. 

Now the object of counter-extension is to prevent the yielding of the 
scapula to the tractive force exerted upon the dislocated member. Nothing 
does this so effectually as the fixing of the opposite scapula by counter-ex- 
tending from the wrist. Not only is the scapula thus sustained, but the 
spine erected and prevented from yielding to the tractive force, and becom- 
ing curved to the injured side, as invariably happens when counter-extension 
is chiefly made from the axilla as is usual. Let the experiment be made 
by allowing a person to_ incurvate the spine laterally, and then making 
traction horizontally from the two wrists. The spine will be immediately 
erected and the two scapulas will at once assume symmetrical positions. 
And so in dislocation, the symmetry of the two sides tends at once to be 
restored. The head and spine are elevated, the two scapulas firmly sus- 
tained, and effect is given, both to the tractive force, and to the necessary 
manipulation. 

In some of the first cases in which I employed this method, I directed 
simply traction from the two wrists, and I am not now confident that this 
is not the best method. I placed the patient in a chair and directed two 
strong persons to make steady horizontal traction from the two wrists. 
As soon as the spasmodic resistance of the muscles was overcome, the head 
of the bone was disengaged, and the muscles which help us in such cases, 
suddenly lifted the head into its place. It will be observed that this method 



22 Smith, Dislocations of the Shoulder- Joint. [July 

causes no appreciable pain, but rather relieves the suffering of the patient 
caused by the pressure of the head of the humerus. 

It is now some twenty years since I commenced the use of this method, 
I am not, therefore, premature in expressing my confidence in it, and re- 
commending it to the profession. 

In cases in which, from unusual muscular development, or the age of the 
dislocation, much resistance is expected, I have modified the application of 
the counter-extension thus : — 




I place the patient in a chair, sitting a little on one side of it, so as to 
allow room on the side of the injury for the operator's foot. I then pass 
a piece of stout muslin, folded, around the chest and under the axilla of the 
injured side. The tails of it I carry horizontally to the opposite side, one 
in front, the other behind, and extending the arm horizontally, bandage 
them firmly to the wrist of the sound side, leaving the ends projecting, to 
be well secured to the wall, or other unyielding substance. 

I then pass an ordinary roller over the top of the injured shoulder, and 
back and forth, twice under the muslin band, to prevent its slipping down. 
Then I continue the same roller under the bottom of the chair and over 
the shoulder, three or four times. This helps to give steadiness to the 
scapula, and especially to prevent the involuntary rising of the patient 



1861.] 



Smith, Dislocations of the Shoulder- Joint. 



23 



from the chair, or the tilting of the scapula upward, when it is necessary 
to make the manipulation of which I am to speak. 

I now attach the extending band to the wrist of the injured side. I am 
aware that this is counter to the practice of many very eminent surgeons, 
especially Sir A. Cooper. My reasons are these : First, the wrist furnishes, 
as we may say, a very convenient handle to the arm. The band employed, 
if properly attached, does not slip, nor lacerate the integuments. In cases 
in which no great resistance is expected, it can be conveniently grasped by 
the hands only of one or two persons. In the next place, this method 
gives much more mechanical advantage in the way of leverage, in executing 
the final manipulations by which the head of the bone is thrown into place. 
It also removes the bands and hands of the assistants further from the 
patient's chest, and gives the surgeon more free access to the shoulder and 
more command of the arm. 

The principal argument in favour of attaching the extending bands 
above the elbow is the relaxing, by this method, of the biceps muscle,, 
which, by the complete extension of the forearm, is rendered tense. This 
disadvantage in my opinion is more than counterbalanced by the advan- 
tages mentioned above. The biceps is not capable of insuperable resist- 
ance; besides, a certain tension of its tendon, where bound to the head and 
neck of the bone, is favourable to the reduction, and it is partly the action 
of this muscle that finally, with a sudden shock, restores the bone to its 
place. Besides, when the bands are applied above the elbow, the forearm 
being at right angles, from the form of the arm, if any considerable trac- 
tion is made, they will invariably slip over the elbow, make very painful 
pressure on the sensitive parts in the bend, of the elbow, and not only cause 
great suffering, but extend the forearm and thus defeat the object in view, 
so that the advantage sought is lost, and many disadvantages encountered. 

I first apply a wet roller to the wrist, and then attach a muslin band by 
the clove hitch. Next I direct the extension to be made by two persons, 
at first outward and a little downward, gradually raising the arm to the 
horizontal direction, and finally a little above it. The extension must be 
made gently and steadily — gradually increasing the force, so as not to pro- 
voke the muscles to spasmodic resistance. As no pain is created by the 
force thus employed, it may be continued for a considerable time. The 
muscles, which at first resist, become fatigued and finally relaxed, and, in a 
large majority of instances of recent luxation, the head will slip into place 
without resort to any species of manipulation. I would even continue this 
traction, where much resistance is encountered, for a quarter of an hour 
before modifying the force; but, in case the object is not then effected, let 
the surgeon place his foot on the margin of the chair, and his knee in the 
axilla. Then let the assistants raise their line of traction above the hori- 
zontal as much as possible, and continue it for a moment. The surgeon 
should then direct that the arm be, by a sudden movement, carried down- 



24 Smith, Dislocations of the Shoulder-Joint. [July 

ward while, by extending his foot, he elevates the knee in the axilla. He 
aids the assistants in this by grasping the arm near the elbow and using it 
as a lever. If the first effort is not successful, repeat it. 

Sometimes I place, on the knee, a ball made by rolling up a bandage, but 
it is not important. The surgeon can thrust his knee into the axilla so as 
to avoid much pressure on the marginal muscles of the axilla. 

I generally direct those who make the traction to sway the limb hori- 
zontally backward and forward, and, grasping it with my hands, at times 
rotate it a little on its axis, thereby contributing to the disengagement of 
the head of the bone. 

Where the consecutive displacement under the coracoid has occurred, the 
procedure is nearly the same, except that I make the traction a little more 
in the direction backward and upward, so as to disengage the head from 
under the process. 

The dislocation upon the dorsum scapulae, as I have before remarked, I 
have never seen but in three instances, and only one of those was a recent 
case justifying the attempt at reduction. It had been dislocated five days, 
and had resisted an attempt at reduction in the hands of others. The 
subject was a female, and I could obtain no very satisfactory account of the 
mechanical mode of the injury. It was easily recognized, there being a 
tumour beneath the spine of the scapula, as Sir A. Cooper describes, of 
the size of the hemisphere of a small orange, the limb being shortened and 
thrown forward. A depression existed under the anterior margin of the 
acromion. I failed to effect the reduction in the method usually recom- 
mended, and which I had deemed the best. I did not then practise exten- 
sion from the opposite wrist. I made it by . carrying the arm through a 
slit in a sheet. The extension was effected from the wrist, and when con- 
tinued for some time, I sought to throw the head into place by manipula- 
tion — that is, I placed my knee against the back of the neck of the bone, 
and, swinging the arm backward, endeavoured to prize the head into its 
place. I repeated the effort several times, but with no satisfactory result. 

I then carried a band over the front of the shoulder, one tail under the 
axilla, the other above it. These I united, carried them backward and in- 
ward obliquely, and secured them to the wall. Then I made traction 
strongly from the wrist almost directly forward. "Without much difficulty 
I thus drew the head of the bone forward over the margin of the glenoid, 
and had the satisfaction to see it slip into its place. 

Much has been said of late of the sufficiency of manipulation, to the 
exclusion of extension, in the treatment of dislocations. By employing 
new terms, and ignoring the precepts of old surgeons, claims to originality 
have been set up. Although the term is modern, the method of manipu- 
lation has been practised for centuries. It is, in my opinion, ridiculous to 
throw away the advantages derived from extension for the sake of magni- 
fying the importance of a particular method of manipulation. Mothe, a 



1861.] 



Smith, Dislocations of the Shoulder- Joint. 



25 



long time ago, reduced the dislocation of the shoulder into the axilla by 
placing the patient in a supine position, and carrying the arm outward and 
finally upward, parallel with the head and neck, making traction at the 
same time. 

It is well known that a recent dislocation into the axilla, may some- 
times be reduced by placing the knee in the axilla, one hand being placed 
on the shoulder, and the other using the humerus as a lever. 

The supine position of the patient on a table is a very convenient 
arrangement in all dislocations of the shoulder, and is well calculated to 
promote the efficiency of the method which I recommend. I am not sure 
that it is not the very best, especially when chloroform is employed. 

It will be observed, then, that I advise the combination of traction and 
manipulation. It would be as absurd to reject traction in all cases of dis- 
location, as it would be to attempt the reduction, by manipulation alone, of 
the fractured femur, where overlapping and shortening had occurred. 

I will, at a future time, furnish for this Journal several cases illustrative 
of the method I have adopted. I will here state, however, that I have, by 
this mode, repeatedly reduced the dislocation of the shoulder which was 
two months old, and once when three months had elapsed. My class in 
the University of Maryland, in February last, witnessed the reduction of a 
dislocation on a muscular man some ten days after the injury. Repeated 
attempts had been unsuccessfully made, and the integuments had been much 
chafed. The extension and counter -extension were continued in the mode 
which I have described, for about five minutes, and then, by a slight effort, 
the knee being in the axilla, the head was thrown into its place. Scarcely 
any pain was inflicted. 

In cases in which I expect great resistance I commonly employ chloro- 
form. Whatever may be the propriety of using this agent for purely 
anaesthetic purposes in minor surgery, there can be no question of the pro- 
priety of resorting to it in difficult dislocations, inasmuch as we have two 
objects in view, the one immunity from pain, the other, relaxation of the 
muscles. The effect of the agent, however, must be rendered very complete, 
for the incomplete use of it causes spastic rigidity of the muscles and 
defeats the object. 

I was not long since called to a case in a very muscular man by a friend, 
who had attempted the reduction unsuccessfully, having given chloroform. 
He had used it cautiously and not with full effect. I then gave it freely, 
till relaxation was complete, and accomplished the reduction with perfect 
ease. 



26 



Winne, Excision of the Head of the Femur. 



[July 



Art. II. — Statistical Inquiry as to the Expediency of Excision of the 
Head of the Femur. By Charles K. Winne, M. D., of Buffalo, N. Y. 

Resection of some of the larger joints dates from the most ancient times, 
having been proposed by Hippocrates 1 and advised by Celsus in compound 
luxations and fractures when reduction could not be effected, and also advo- 
cated in certain diseases of the bones by Paulus JEgineta 2 and Rhases ; but 
the two latter writers, who alone mention the hip-joint, denounce all ope- 
rative interference with it as involving too much danger to life. 

The inception of excision of the head of the femur dates from a late 
period. The credit of suggesting it as an operation worthy of consideration 
has been awarded to Mr. Charles White, 3 of Manchester, who proposed 
it, as follows: "I have likewise, in a dead subject, made an incision on the 
external side of the hip-joint, and continued it down below the great tro- 
chanter, when cutting through the bursal ligaments, and bringing the knee 
inwards, the upper head of the os femoris hath been forced out of its socket 
and easily sawn off ; and I have no doubt but that this operation might be 
performed upon a living subject with every prospect of success." This is 
the first mention of an operation rendered formidable by the character of 
the disease or injury for which excision is deemed necessary, the magnitude 
of the parts implicated, and the results which often succeed its performance. 

In 1818 an appropriate case having presented itself to Mr. Anthony 
White, 4 the first operation of the kind was done with the most gratifying 
result. It was subsequently performed in two other instances by Sir B. 
Brodie and Mr. Hewson, but these terminating unsuccessfully, the operation 
was regarded with disfavour by the profession until 1845, when it was revived 
by Mr. Fergusson. 5 Since then it has been done in gunshot wounds and 
the latter stages of morbus coxarius, and by the labours of Fergusson, 
Jones, Stanley, and others, has assumed the status it deserved. 

As the expediency of an operation of such intrinsic importance can only 
be satisfactorily ascertained by having recourse to statistics, I have endea- 
voured by the analytical collation of cases to deduce some data for the fur- 
ther elucidation of so interesting a question, and as cases for which the 
operation is applicable naturally separate into those dependent upon trau- 
matic lesions, and those justified by the sequences of disease, I will pass in 
rapid and brief review the two classes of cases for which it is considered 
requisite. 

1 Hippocrates "On the Articulations," sec. 68, and note. 

2 Paulus iEgineta, "book vi., sec. 77, and note, sec. 84. 

3 White's Cases in Surgery. 

4 Cooper's Surgical Dictionary, article " Bones." 

6 Medico-Chirurgical Trans., vol. xxviii., or Medico-Chirurgical Review, April, 
1846. 



1861.] 



Winne, Excision of the Head of the Femur. 



27 



In military surgery the most eminent authorities from the time of Heis- 
ter onwards, have coincided in the statement that the hazardous nature of 
wounds of the joints and the deplorable mortality arising from attempts 
to save them, have necessitated amputation in all severe cases of gunshot 
wounds communicating with them. This is more especially the case in 
gunshot wounds of the hip-joint, for Mr. Alcock's 1 experience in this form 
of injury was that "the result is generally fatal; three in four died; and 
in the fourth, when recovery took place, the joint itself, there is some reason 
to suspect, was but remotely affected." Dr. Thomson 3 also recommended 
immediate amputation at the hip-joint when "a musket-ball or grapeshot, 
or a small portion of shell has been observed to fracture the neck of the 
thigh-bone or to fracture the head of that bone, and pass through or lodge 
in the hip-joint. The proportion of cures which has been obtained from 
amputation at the hip-joint is, I believe, much greater than of cures from 
gunshot fractures of the head or neck of the thigh-bone. Indeed, of reco- 
veries from these injuries I know of none which have been recorded. Those 
who for a time seem to do well, in the end sink under the hectic which 
supervenes." This is the opinion of all military surgeons, and Stromeyer, 
one of our recent authorities, says: "Left to themselves, all injuries of the 
femur close to the hip-joint must end fatally." 

But the opinions of surgeons have gradually undergone modification 
since excision of other joints has been attended by success, both as regards 
a diminished ratio of mortality and a more or less complete use of the 
limb ; and excision is now considered more applicable and as affording a 
better chance of success than amputation at the hip-joint, in those cases in 
which the fracture of the head and neck of the femur is unaccompanied by 
great laceration of the soft parts, injuries of the vessels, or extension of 
the fracture below the trochanter major; the presence of these lesions of 
course contraindicating it and affording no resort save disarticulation. 

In confirmation of these views Mr. Guthrie 3 says: "Picture to yourselves 
a man lying with a small hole, either before or behind, in the thigh ; no 
bleeding, no pain ; nothing but an inability to move the limb, to stand 
upon it, and think that he must inevitably die in a few weeks, worn out by 
the continued pain and suffering attendant on the repeated formation of 
matter burrowing in every direction, unless his thigh be amputated at the 
hip-joint, or he be relieved by the operation which, I insist upon it, ought 
first to be performed." 

Sir George Ballingall 4 remarks that the "experience which we have of 
excision of the head of the femur, in cases of caries, is now considerable, 
and appears to me to be encouraging ; and since I have become familiar 
with the excision of other joints, I have frequently reflected upon the pos- 

1 Medico-Chirurgical Trans., vol. xxiii., or Medico-Chirurg. Review, April, 1841. 

2 Quoted in Sir Gr. Ballingall's Outlines of Military Surgery, p. 441. 

3 Commentaries on Surgery, p. 77. 4 Outlines of Military Surgery, p. 397. 



28 



Winne, Excision of the Head of the Femur. 



[July 



sibility of substituting the operation of excision for that of amputation at 
the hip-joint, in some of those cases of gunshot wounds where the latter 
has been recommended." 

The most complete and valuable data heretofore obtained were acquired 
by the English during their campaign in the Crimea. Mr. Macleod, 1 in 
narrating the uniformly fatal termination at an early period of the cases 
in which amputation at the hip-joint was done, declares that "all those, 
on the other hand, on whom excision was practised, lived in comparative 
comfort, all without pain for a considerable time. Out of the six operated 
on one survived for more than a month, one died from causes unconnected 
with the operation, and one case recovered entirely. The chance of saving 
life is thus manifestly on the side of excision, and this is truly the most 
important aspect of the question." 

An operation which has thus met with the approval of those best quali- 
fied to judge will probably eventually supersede amputation at the hip-joint, 
as its results are more favourable in those cases of injury of the head and 
cervix of the femur unattended by the complications before mentioned. 

The cases in which this operation has been performed for gunshot wounds 
are as follows : — 

Case I. Seutin removed six inches of the femur, including the head and 
cervix, in a comminuted fracture of the cervix attended with but little lace- 
ration of the soft parts, followed by death on the ninth day from gangrene. 2 

Case II. Oppenheim removed the femur close to the trochanter minor 
in a fracture of the head of the cervix and trochanter major, from a musket 
ball. Death took place on the eighteenth day. 3 

Case III. Schwartz performed a secondary operation, removing the for- 
mer "two inches below trochanter minor." Death on seventh day from 
pysemia. 4 

Case IY. Ross operated two years after injury, followed by death. 5 

Case Y. Macleod, in a case of fracture of the trochanter major and 
cervix received from a ball which had also fractured the ulna, removed the 
necrosed bone and the head of the femur eighteen days after injury. Erom 
the rapid improvement of the condition of the patient and the healthy 
appearance of the wound, a portion of which had healed, hopes were enter- 
tained of his recovery; but about a week after choleraic symptoms super- 
vened with a fatal result. Crude tubercles were found on examination, and 
the intestines presented appearances of diseased action. The limb was 
shortened two inches, and the divided surface was unchanged. No symp- 
toms of pyasmia were discovered. 6 

Case YI. Blenkins operated primarily in a case of injury from shell, 
which produced extensive laceration of the soft parts, and a comminuted 
fracture of the neck and trochanters. The femur was divided "at the 
junction of the upper fifth with the rest of the shaft," and the injury of 

1 Notes on the Surgery of the Crimean War, p. 346. 

2 Chelius ; System of Surgery. 3 Ibid. 

4 Macleod ; Surgery of Crimean War. 5 Surgery of Crimean War. 6 Ibid. 



1861.] 



Winne, Excision of the Head of the Femur. 



29 



the capsular ligament necessitated removal of the head of the femur also. 
The end of the femur and acetabulum were granulating well, and the con- 
dition of the patient was favourable, but pyaemia occurred at the end of the 
third week, causing death at the expiration of a fortnight. 1 

Case YII. Crerar, a few hours after a comminuted fracture through the 
trochanter major had been made by a fragment of shell, the external wound 
being small, divided the femur below the seat of injury, removed fragments 
and then excised the head of the bone. The patient died of exhaustion on 
the fifteenth day after receipt of injury. "Cut surfaces of the femur per- 
fectly smooth; bone easily divested of its periosteum; acetabulum smooth; 
muscles infiltrated with pus; nature had not made the slightest attempt to 
repair the loss." 2 

Case YII I. O'Leary excised the head of the femur in a case of fracture 
of the trochanter major that appeared to involve the joint, which was 
incorrect, however, the head of the bone being uninjured; five inches of 
bone were removed; the man recovered, and the report several months after 
was that "the limb is two inches shorter than the corresponding one, and 
also considerably smaller; extension can be carried on partially, but he 
cannot flex the limb upon the thigh without placing his hand on the glutei 
muscles of the diseased side. Rotation, inwards and outwards, can be 
performed only to a limited extent. The wound over the joint is quite 
healed. The man's general health is good, but he cannot walk without 
the assistance of crutches. 3 

Case IX. Hyde operated primarily for a comminuted fracture of the 
cervix. The patient died on the fifth day. 4 

Case X. Combe operated, not primarily, however, for a fracture of the 
cervix, the head of the bone being sound. The man died at the expiration 
of a fortnight of exhaustion. 5 

Though but one case of excision recovered out of ten subjected to it, 
yet, on comparing the result of this operation with the alternative of 
amputation at the hip-joint, we find that out of 126 cases 6 on whom am- 
putation at the hip-joint was done, 16 died; or, restricting our inquiries 
entirely to amputation at the hip-joint for gunshot wounds, out of 62 
cases 7 operated on, but 5 recovered, being a mortality of 91.9 per cent. 

I have found but one case recorded where the operation has been done 
as suggested by Jaeger, for abscess consecutive to fracture of the neck of 
the femur ; 8 in this case the head and neck of the femur and two inches of 
the great trochanter were removed, by Textor, from a child of seven and a 
half years, followed by a fatal result on the twenty-third day. After death, 
the pelvis was found to have been fractured. 

In estimating the value of the operation in morbus coxarius, we find that 

1 Surgery of Crimean War. 

2 Guthrie's Commentaries on Surgery. 3 Surgery of the Crimean War. 
4 Surgery of the Crimean War. 5 Ibid. 

6 Erichsen's Science and Art of Surgery, 2d edition, p. 43. 

7 Notes on the Surgery of the Crimean War. 
s Chelius' System of Surgery, vol. iii. 



30 Winne, Excision of the Head of the Femur. [July 

even now so little unanimity exists in the profession concerning it, that in 
but very few formal treatises on surgery is it recognized, or its claims ad- 
vanced other than hesitatingly, in giving a hope of prolonged life, where, 
except in rare instances, anchylosis has formed, death has followed, either 
from the patient sinking exhausted, or from the disease extending to the 
interior of the pelvis through a perforated acetabulum. 

No parallel can be drawn between the result of excision in gunshot 
wounds and the termination of the same operation in disease, as in one an 
injury in an adult, of parts, unaltered by long continuance of inflammatory 
action, compels its execution as the least of two evils, while in the other, a 
disease in the great majority of cases of constitutional origin, and one 
peculiarly an affection of childhood and early youth, demands, all other 
treatment having been ineffectual in arresting its progress, a resort to this 
extreme measure, hoping with the removal of the diseased portions which 
react upon the general health continuing and increasing the irritation, that 
a healthy inflammation will be substituted for an unhealthy one, the wound 
will cicatrize, and the patient be restored to health, or at least to a condi- 
tion of comfort. 

I am necessarily debarred from making any remarks upon the pathology 
of hip disease, as the object intended in this paper is more to describe the 
various results succeeding the operation, than to enter upon any elaborate 
statement in regard to the actual correctness of the views which instituted 
its practice. The cases most benefited by the operation, in the judgment 
of those most warmly in favour of it, are those which, in Mr. Erichsen's 
classification, constitute the femoral variety of the disease. 

In these cases the head of the femur alone, or the cervix also, being 
carious; dislocation existing; the presence of sinuses through which ne- 
crosed bone is detected; abscesses exhausting by their continual formation 
and discharge; the intense suffering produced by the slightest motion; the 
health affected and manifested by hectic fever, night-sweats, and a deprava- 
tion of all the secretions — all indicate the propriety of interference when the 
acetabulum is either healthy or but moderately affected, or when the con- 
dition of the patient is not so far reduced as to forbid the additional hazard 
of an operation. 

I may incidentally mention that in the arthritic form, much may be done 
by the application of a properly adjusted apparatus, keeping the limb ex- 
tended and motionless, toward promoting more or less complete anchylosis. 
Cases reported by Mr. Erichsen, 1 Mr. South, 3 and others, show that this 
mode of treatment is not confined to the earlier stages of the malady, but 
that it can sometimes be used with great advantage when dislocation upon 
the dorsum of the ilium has occurred before the formation of abscesses. 

The following table comprises all the cases operated on for morbus 
coxarius which I have been able to collect : — 



1 Medical News, June, 1857, or Lancet, March 28, 1857. 2 Lancet, Feb. 1858. 



1861.] 



Winne, Excision of the Head of the Femur. 



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34 Winne, Excision of the Head of the Femur. [July 



An abstract of the above table of 49 cases operated on for caries affords 



the following results : — 

20 cases recovered. 

5 " convalescing or doing well. 

6 " were improved. 
15 " died. 

3 " the result was not stated. 

Total 49 

Though great relief was experienced from the operation, yet other dis- 
eases eventually caused a fatal termination in four of the cases noted as 
improved ; one dying after a few weeks and the others lingering for some 
months, the wound in one never entirely closing owing to the presence of 
necrosed bone. Suppuration still continued in the two others when re- 
ported, and necrosed bone was removed from one several months after. 

The time of death in those cases resulting unfavourably is noted in the 
reports of 16 cases. 5 cases terminated fatally on or before the seventh 
day; 1 in a few days; 1 before the expiration of a fortnight; 4 before or 
during the third month ; 2 after an interval of several months ; and 3 at 
an advanced period, ranging from one to three years. 

The causes of death including in this enumeration the diseases which 
carried off those marked as improving, are stated in the records of 15 cases. 
Viewing death as arising both from the operation and its consequences, 
and as depending upon the complications of other diseases which might 
arise under any circumstances, and which cannot per se be regarded for 
that reason as exercising any adverse influence upon the operation in other 
cases, we find that death ensued, 

As the direct effect of the operation in . . . .1 case. 

From long continued and profuse suppuration . . 2 cases. 

Gangrene . . . . . . . .1 case. 

Secondary hemorrhage and exhaustion . . . . 1 " 



5 cases. 



Diseases causing Death. 

Enlargement of the liver .... 
Bright's disease of kidney and lumbar abscess 



Phthisis 

Dysentery . . . 

Death not attributable to operation 



1 case. 
1 " 
1 " 

3 cases. 

1 case. 
1 " 



Hectic fever ; bedsores ; wound nearly closed, false joint forming 1 " 
\ - 

9 cases. 

Amputation at hip-joint for recurrence of caries . . . .1 case. 

Total 15 cases. 



1861.] 



Winne, Excision of the Head of the Femur. 



35 



The age and sex of the patient, as might a priori be expected, influence 
in a great measure the frequency and result of the operation. The follow- 
ing tabular forms comprise the most important points connected with this 
part of the subject, excluding the three cases of whom the only informa- 
tion respecting their age is that they were children, and classing the two 
adults in the last table. 



No. 1. — 10 years of age or younger. 

13 cases, 8 males, 5 females. 
8 recovered. 
1 improved. 

1 result not stated. 
3 died. 

No. 2. — Between 10 and 15 years. 

10 cases, 7 males, 3 females. 
5 recovered. 

2 convalescing. 

1 result not stated. 

2 died. 



No. 3. — Between 15 and 20 years. 
6 cases, males. 

1 recovered. 

2 convalescing. 

1 improved. 

2 died. 

No. 4. — Above the age of 20 years. 

5 cases, 3 males, 1 female, 1 
sex not given. 
1 recovered. 
1 improved. 

3 died. 



One of the most serious objections urged against the operation by its 
opponents, of whom Mr. Syme 1 is the most prominent and unsparing, is 
that the acetabulum being almost always affected, the extension of the dis- 
ease to the pelvis renders futile all attempts to prolong life by the excision 
of the diseased portions of the femur. The condition of the acetabulum 
is noted in the preceding table in 32 cases. 

Acetabulum bealthy ; 1 recovered, 1 died ...... 2 

Acetabulum absorbed, altered in form or filled with, new growth of plastic 

matter; 3 recovered ; 2 convalescing ; 1 result not stated ; 1 died . 7 

Not sufficiently diseased to require interference ; 2 recovered ; 1 improved 3 
Small part of margin or centre of acetabulum removed ; 1 recovered ; 1 

convalescing ; 4 improved ; 3 died ; 1 result not given . . .10 

Acetabulum extensively diseased ; 4 recovered ; 2 died .... 6 

Perforation of acetabulum and pelvic abscesses ; 2 recovered ; 2 died . 4 

Total cases 32 

I have since found that the above table agrees substantially with the 
researches of Mr. Hancock upon this point ; in those it is stated, that "in 
19 of 27 operations performed, the acetabulum afforded more or less 
evidence of disease at the time of operation. In two there was scarcely a 
trace of acetabulum. In three the acetabulum was filled with a fibro-gela- 
tinous mass. In six the gouge was employed for caries. In three it was 
perforated, and in the others it was more or less affected." 2 

1 Treatise on the Excision of Diseased Joints, p. 124; Edinburgh, 1831. 

2 British and Foreign Medico-Chirurgical Review, October, 1857, p. 307. 



36 Winne, Excision of the Head of the Femur. [July 

Owing to the limited number of cases which have been subjected to post- 
mortem examination, only an approximate idea can be formed concerning 
the ultimate changes taking place in the parts toward the formation of a 
false joint. Mr. Walton 1 speaks of a specimen in which the extremity of 
the femur was rounded off and connected by ligament with the acetabulum. 
In a specimen in the possession of Mr. Jones, 2 the end of the femur was 
connected with the ilium above the cotyloid cavity by an almost complete 
capsule of fibrous tissue ; the acetabulum having been partially absorbed. 
In Wagner's work on Resections, the appearances of several cases are 
described. In one, two bony prominences formed from the remainder of 
the neck of the femur were connected, one above, and the other with the 
original acetabulum (Case 47), by fibrous tissue. In another who died 
before the reparative process was completed (Case 8), deposit of new bone 
had taken place on portions of the acetabulum, and on the. femur, the 
extremity of which was rounded off, and a new irregularly shaped aceta- 
bulum was being formed on the ischium where the femur rested. In a 
third case (Case 2), the bones were united by fibrous tissue, a portion of 
which consisted of part of the original capsular ligament. Anchylosis 
had once been present in a case (No. 48) which terminated unsuccessfully, 
subsequent amputation having been necessary. In only one case (No. 49), 
where dysentery caused a fatal result in three months, is mention made of 
cartilage being formed upon the divided surface of the femur ; in this case 
also the acetabulum was being filled up with granulations, save in one spot 
where a portion of necrosed bone was undergoing disintegration. 

The only conclusions we can arrive at from such a paucity of cases, are, 
that in all probability the bone undergoes after excision the same changes 
which occur after amputation ; that is, its medullary canal becomes oc- 
cluded, its extremity rounded off and connected either near the acetabulum 
or with it by fibro-ligamentous tissue, forming the first variety of false 
joints, described by Rokitansky; 3 or very rarely, perhaps, as in the case 
before mentioned, by the deposition of cartilage and the formation of a 
more or less perfect capsular ligament. 

In the preparation of this succinct account of the principal points of 
interest connected with the history and practice of excision of the head of 
the femur, I have omitted all mention of the various modes of operating, 
and the manner of dressing the limb subsequently, believing that from 
other sources more information relating to these matters can be acquired 
than can be advantageously compressed into the brief notice I can give 
them. 

Several cases which I have seen incidentally mentioned by various 

1 Lancet, June, 1850, p. 617. 

2 Medical Times and Gazette, Nov. 4, 1854, quoted in Braithwaite's Retrospect, 
Part 31. 

a Pathological Anatomy, vol. iii. 



1861.] Clements, Notes of Surgical Cases. 



writers, I have omitted ; for the reason, that I cannot refer to any very 
authentic histories of them. 

I have also, as far as possible, avoided extended comments upon the dif- 
ferent classes of cases, or from deducing conclusions from them other than 
those naturally flowing from them. 



Art. III. — Notes of Surgical Cases. By B. A. Clements, M. D., 
Assistant Surgeon U. S. Army. 

Case 1. Bayonet wound through the abdomen ; recovery. — The gene- 
rally fatal nature of penetrating wounds of the abdomen renders more inte- 
resting and worthy of note those exceptional cases, in which the abdominal 
cavity has been penetrated by large and even sharp instruments and the 
wounds have been followed by " inconceivably" rapid recoveries. Cases 
of this exceptional character, of which the following is a rare example, 
have been related by Pare, Wiseman and others. 

Musician E., 7 th Regiment Infantry, age 32 years, a healthy temperate 
man, of spare figure, received on 17th June, '58, at the crossing of the 
"Big Blue" River, Kansas, a wound from a bayonet in the hands of a 
deserter which entered at the free extremity of the last false rib on the left 
side two inches above the crest of the ilium and about four inches from the 
spine, and emerged at the opposite side of the body, at the edge of the 
cartilages of the false ribs, two and a half- inches to the right of the me- 
dian line. 

The wound was inflicted early in the morning while the patient was 
fasting, and at the moment he was in a stooping posture, which threw the 
left side higher than the right ; the bayonet was run up to the hilt, and 
the patient grasped its point as it emerged through the right side. 

There was very little hemorrhage from either wound ; he walked a few 
steps, but then fainted. The wound was simply dressed with cold water, 
and he was left at a cabin near the roadside with a careful attendant. 
During the day he rejected all fluids taken into the stomach, and in the 
evening had great pain over the whole abdomen, and was unable to extend 
the left thigh and leg : he was taken with hiccough, which soon gave 
place to a severe convulsive movement attended with twitching of the face, 
and coldness of the body, but without insensibility ; these attacks were 
each of some minutes' duration and recurred five times during the night. 

The following day he had fever, high-coloured urine and frequent mictu- 
rition, and his abdomen was painful, swollen, and hard. On the 1 9th, two 
days after the receipt of the wound, he suffered so much from these symp- 
toms that the attendant gave him "a dose of calomel and rhubarb," and, 
the pain increasing towards evening, he cupped him over the abdomen and 
immediately after applied a blister ; at night he had two free evacuations 
from his bowels, which gave him great and speedy relief from the pain, 
after which he obtained some sleep. 



88 



Clements, Notes of Surgical Cases. 



[July 



On the 21st I saw him for the first time with Assistant Surgeon Wil- 
liams, when we received the foregoing account from the attendant, a very 
reliable intelligent man who had been left with him. The particulars as to 
the infliction of the wound were confirmed from other reliable sources, and 
from the patient himself. 

The triangular shaped wounds of the bayonet were found in the positions 
already mentioned, that in the left loin being the largest, and both in pro- 
cess of healing ; his countenance was good, pulse regular and of normal 
frequency, tongue clean, and but little thirst ; there was no pain on pressure 
in the course of the wound, nor at any part of the abdomen, except a 
small spot in the left iliac region and upper inner side of the left thigh; 
the urine was rather high coloured, but presented to the eye no indication 
of blood, and particular inquiry elicited nothing to induce the belief that 
it had at any time been bloody; he passed it without difficulty, and was 
still unable to extend his left thigh. A quarter of a grain of morphia 
three times a day was directed, complete repose and the lowest diet. 

22c?. Pulse normal ; slight pains still in the right iliac region, increased 
by attempts to extend the thigh ; bowels moved naturally last night. 
Treatment continued. 

2Qth. Ninth day. He has steadily improved to this date on the lowest 
diet, and without an untoward symptom, and, with the exception of some 
slight pain about the left groin when he extends the leg of that side, he is 
now well. 

He soon after joined his regiment, and made the long and wearying 
march to Utah, and when I last saw him, more than a year afterwards, he 
continued quite well, suffering no other inconvenience from his wound than 
a dull pain in his left loin when he ran or jumped. 

The great and speedy relief to the abdominal distress by the operation 
of a cathartic is convincing proof that though the abdomen was fairly 
transfixed the bowels were uninjured, even if the exceedingly rapid recovery 
did not place it beyond doubt. 

The hiccough may be referred to penetration of the lower part of the 
diaphragm, and the pain in the left groin and thigh to injury of the psoas 
muscle and the lumbar plexus. 

Case 2. Prolapsus ani with chronic inflammation of the rectum, 
cured by the local applicaiion of pure nitric acid. — The local application 
of pure nitric acid for the cure of certain forms of ha3morrhoids was some 
years since recommended by the late Dr. Houston, of Dublin, but attention 
was first called to its use in prolapsus ani by Mr. Henry Smith, Surgeon to 
the Westminster Dispensary, London, in the Medical Times and Gazette for 
January, '58, who there speaks in high terms of its efficacy in the complaint 
and who has more recently published a work on the subject in which this 
favourable opinion is amply sustained by his subsequent experience. 

Private L., 7th Regiment Infantry, a German of nervous temperament, 
aged 32 years, was admitted to hospital at Camp Floyd, Utah, November 
26th, '58, complaining of "piles." In 1852 he contracted dysentery while 
on the expedition to Red River under Captain Marcy, and since that time 
had had repeated attacks, attended, he says, with "piles." The surgeon of 



1861.] 



Clements, Notes of Surgical Cases. 



39 



the post at which he was stationed at the expiration of his first enlistment, 
refused to re-enlist him in consequence of this disease, but he again enlisted 
elsewhere, though he had never been free from his complaint. In May, 
'58, at Fort Leavenworth he had another severe attack of dysentery, from 
which he had suffered more or less up to the time of his admission. 

He was treated by the usual internal remedies and astringent applications 
up to February, 1859, without material benefit. An examination at this 
time revealed a marked degree of prolapse of the rectum, the protruded 
mass being about 2J inches in diameter, of a vivid red colour, and its 
surface covered with a viscid layer of yellow unhealthy looking mucus : 
his bowels were moved from four to six times a day, the evacuations being 
small and always attended with much pain, straining and prolapse of the 
parts, which last he had, however, learned to reduce without much difficulty. 
He was pale and cachectic in appearance, had poor appetite, and was ex- 
ceedingly nervous and low-spirited. 

On February nth I applied pure nitric acid to the prolapsed parts. 
Having previously administered a small dose of castor oil, the parts were 
freely exposed by straining, and having cleansed the surface of the thick 
tenacious dark-yellow mucus which covered it, the pure acid was freely 
applied over the whole surface without touching the skin. 

The application was unattended by any pain or uneasiness except a slight 
stinging sensation, but was immediately followed by an ash-coloured eschar. 
The parts being then bathed with cold water for some minutes were 
returned, and the recumbent posture with low diet enjoined. Two grains 
of opium were given at night. 

18th. There has been a slight discharge of blood, but he has no pain, 
and his bowels have not moved. Ordered one grain of opium three times 
a day ; recumbent posture to be maintained. 

On the 19th his condition was the same; on the 20th he had one 
evacuation from his bowels unattended with pain, and neither during nor 
after the evacuation did the bowel protrude, which had not been the case 
before for nine months. 

21st. He had one evacuation without prolapse of bowel. 

22c?. The stool was tolerably firm and unattended with pain ; but it was 
narrow and flattened in shape, and was followed by a discharge of about 
one drachm of blood. 

24th. The stool to day was larger in size than on the 22d and was but 
slightly flattened. 

On examination, no protrusion or eversion of the rectum could be per- 
ceived even on moderate straining. On introducing the finger there seemed 
to be a thickening of the mucous membrane, and some contraction of the 
calibre of the rectum for about two inches, but the parts were not dense or 
resisting to the touch ; this condition was probably due to a temporary 
swelling of the mucous membrane. 

On the 2tth, by causing him to strain violently I obtained a glimpse of 
a very small portion of the mucous membrane, which was very red, but 
not ulcerated. He had now not the slightest eversion of the parts at stool, 
and he was free from the distressing tenesmus from which he formerly 
suffered so constantly. Opium, which of late had only been given at night, 
was withdrawn, his diet was increased, he improved very rapidly in general 
appearance, and was returned to duty on 6th of March, eighteen days after 
the operation. 



40 



Clements, Notes of Surgical Cases. 



[July 



The shape of the evacuation noted on the fifth day after the application 
of the acid was probably due in some degree to temporary swelling of the 
mucous membrane, but in greatest measure to irritability or spasm of the 
sphincter ani. 

Five months afterwards I again examined this patient. I found he could 
produce some eversion of the mucous membrane by hard straining, but it 
was of perfectly healthy appearance, being of a pale pink colour, the 
rectum seemed to preserve its normal calibre, but he stated that his 
feces were somewhat flattened in shape, due I believe to irritability of 
the sphincter which had' evidently great power. His bowels moved 
regularly, he was free from dysenteric discharges, and had improved very 
much in his general health. Occasionally he has had a slight eversion of 
the mucous membrane at stool, never, however, amounting to prolapse, 
or occasioning inconvenience, but he has always been able to draw it back 
simply by contracting the sphincter. Until this operation he had not been 
free from dysenteric discharges of bloody mucus and prolapse of the rectum 
for some years. He continued well up to November, 1859, when I last 
saw him, and up to that time had not lost a day's duty by sickness. 

Case 3. Communication of secondary syphilis ; transmission of in- 
fection from a secondary sore. — The following case, which came under 
the notice of several of the medical officers of the army in Utah, and 
which was for some time under my care, is a marked example of the 
production, by contact with a secondary syphilitic sore or its secretion, of 
an ulcer with all the characters of a chancre, which ulcer was followed by 
constitutional syphilis. 

Mrs. E., a Mormon woman aged 17 years, was married on 16th Decem- 
ber, 1858, to a discharged non-commissioned officer of dragoons ; though 
not robust she had always enjoyed excellent health up to the time of her 
marriage. 

She believed that she became pregnant within a month or six weeks after 
her marriage. 

The medical history of her husband was as follows : He contracted a 
chancre on the penis at Fort Leavenworth in July, 1857, and having im- 
mediately after to make a rapid trip across the plains, he was subjected to 
much exposure, and in consequence could not receive the necessary atten- 
tion or treatment for his disease. The chancre, however, was healed during 
the winter of that year, but was followed by sore throat and sores on the 
tongue and inner side of the lips. 

As he himself had not been under my care, I did not examine him ; but 
Assist. Surgeon Norris, whose patient he had been, had carefully and often 
examined him, and kindly informed me that the sores on his tongue and 
in his mouth were undoubtedly syphilitic " mucous papules" or " flat tuber- 
cles and these sores existed at the time of his marriage to the subject of 
this case and for several months subsequent. 

In February, 1859, two months after Mrs. E.'s marriage, her husband 
in caressing her bit her slightly on her upper lip, and she having been 
much exposed to cold on a short journey, this slight wound inflamed, a 



1861.] 



Clements, Notes of Surgical Cases. 



sore appeared, which swelled very much, increased rapidly to the size of a 
dime, became rounded in shape, of a dark red colour with hardened elevated 
edges and a shining base, and discharged a dirty looking secretion. The 
peculiar character of the sore inducing suspicion, Assist. Surgeon Norris, 
under whose care she then was, invited Assist. Surgeons Williams, Getty, 
and myself to see her in consultation, when the sore was found in the 
condition just mentioned, and we all coincided in opinion that it was a 
chancre. 

The local remedies applied to the sore not having produced much benefit, 
she was put upon a course of mercurials, under the use of which the sore 
slowly healed by the end of March. But at this time her throat became 
sore, and an elevated papular port-wine-coloured eruption appeared over 
her whole body and especially upon her face. It was from these symptoms 
she was suffering when she came under my care in May. I found her 
throat much swollen, of a dark red colour, with dirty yellow patches on 
the tonsils and fauces, which were covered with a copious secretion of 
offensive brownish mucus. The appearance of the eruption and of her 
throat was unmistakably syphilitic. She was pale and cachectic in appear- 
ance, and there were also some very superficial simple excoriations on her 
vulva, which had then existed only some two weeks, and were plainly due 
to want of cleanliness ; these were speedily healed by the application of 
lead-water and the observance of cleanliness. 

She was treated with iodide of potassium, bitter tonics, and the applica- 
tion of a strong solution of nitrate of silver to the throat, and by the end 
of July, these symptoms had almost entirely disappeared, and she had re- 
covered in great measure from the pallor and debility under which she had 
laboured. 

On the 15th August, eight months after her marriage, being then apparently - 
free from secondary symptoms, she was prematurely delivered of an imper- 
fectly developed dead child, which was soft and semi-putrid. 

She did not seek advice again up to March, I860, when I last saw her. 

The particulars of this case were ascertained by repeated examinations 
and careful inquiry, and scarcely require comment. Yet it may be re- 
marked that there can be no question as to the character of the sore on the 
patient's lip, nor doubt as to its mode of production. With this efficient 
cause for the secondary symptoms existing, I cannot refer them to infection 
through the foetus in utero begotten by the diseased father ; and an atten- 
tive consideration of the case will, I believe, render the conclusion unavoid- 
able, that a chancre on the lip which caused marked constitutional syphilis 
was produced by the secretions from secondary syphilitic sores in the mouth 
of the patient's husband, acting on an abraded surface. 

On the debated subject of the transmissibility of infection from secondary 
sores, Mr. Harrison in a recent work on syphilis, says : — 

" The effect of the contagion of syphilis, when contracted by transmission 
from secondary sores, is, according to M. Bonnet, of Lyons, an ulcer which 
becomes developed after a variable period of incubation, which presents all the 
characters of the true primary syphilitic chancre, and is, like it, followed by 
other secondary symptoms." — London Lancet, July, 1860. 

The question " Are the secondary symptoms of syphilis contagious ?" was pro- 
pounded to the Academy of Medicine of Paris, by the Minister of Public Works, 



42 



Clements, Notes of Surgical Cases. 



[July 



in 1859, and a committee consisting of Velpeau, Ricord, and others, after in- 
stituting experiments, replied as follows : " There are secondary or constitutional 
symptoms of syphilis which are contagious. The principal of these is the mucous 
papule or flat tubercle." — London Lancet, August, 1859. 

Case 4. Wutzer's operation for the radical cure of hernia ; unsuccess- 
ful. — The following case is illustrative of two of the causes which may 
prevent the success of Wutzer's operation for the radical cure of hernia, an 
operation which would appear to be attended often with favourable results. 

Private M., Tth Regt. Infantry, a German, aged 24 years, stout and healthy. 
A prisoner for desertion, he was made to quarry stone, and contracted an 
oblique inguinal hernia on the left side, which he first observed about 25th 
April, '59. On an examination made June 1st, '59, the hernia was found 
to be voluminous, filling the scrotum ; the inguinal canal was deep and so 
very short as at first to cause the hernia to seem " direct;" the external 
ring was smaller than the internal, and the scrotum and walls of the canal 
tough and resisting. 

A truss was applied for four weeks without benefit, and I determined to 
perform Wutzer's operation in the manner recommended by W. Spencer 
Wells. The case, however, was considered not a favourable one owing to 
the condition of the parts already mentioned. 

The operation was done on the 28th June, in the usual manner. The 
patient was kept in the recumbent posture, and the instrument well sup- 
ported. His bowels had been freely moved previously, and he was put 
upon low diet. In the afternoon, in consequence of some pain in the 
parts, the plate was slightly loosened and Tr. opii gtt. xxx given. 

The following day he complained that the instrument hurt him, and as 
the plate did not press quite evenly near the point it was loosened and 
readjusted. He also complained of pain running up from the inner ring to 
the umbilicus. 

The second day all pain had ceased. 

The third day he had some pain, in the scrotum which I referred to the 
cord ; there was a bluish discoloration at the point of exit of the needle, 
and he could bear the pressure of the instrument better. 

On the fourth day there was some fibrinous incrustation at the base of 
the projecting part of the needle. 

The fifth clay there was a slight excoriation of the skin at the lower edge 
of the point of the plate, and evidence of slight suppuration at the point of 
exit of the needle. 

On the seventh day the suppuration at the point of emergence of the 
needle through the skin of the groin was decided, and a serous exudation 
covered the plug and exuded from the cavity. 

On July 6th, the eighth day after the operation, the plug of the instru- 
ment was coated with a glutinous discharge, and the instrument was re- 
moved. The surface of the plug of skin was excoriated, and the cuticle 
around the puncture of exit of the needle was elevated for a space the size 
of a dime, and the skin was also abraded where the lower edge of the 
point of the plate had pressed. The plug of skin bore considerable traction, 
during which the parts up to the inner ring plainly moved together, show- 
ing that some adhesion had taken place. 

The cul-de-sac was filled with oiled charpie, and the scrotum well sup- 
ported without the application of a bandage. 



1861.] 



Clements, Notes of Surgical Cases. 



43 



The day after the removal of the instrument the plug seemed to have 
come down a little, and with each succeeding day the cul-de-sac became still 
more shallow until on the night of July 16th. Eighteen days after the 
operation the intestine again came down into the scrotum whilst he was 
lying in bed. Two days afterwards the cul-de-sac was entirely obliterated, 
and the hernia was in the same condition as before the operation. Both 
the punctures made by the needle had entirely healed. 

Some union of the opposed surfaces had evidently taken place; the in- 
strument may perhaps have been removed too soon, yet the failure of the 
operation must be ascribed in greatest measure to the causes which before 
its performance were considered as unfavourable to its success, the shortness 
and depth of the inguinal canal, and the dense and powerful scrotum whose 
contraction doubtless loosened the soft adhesions. 

The instrument used was incapable of being adapted to varieties in the 
shape and size of the rings and canal, and an operation which I saw per- 
formed with it after the above, though the case seemed a most favourable 
one, was unsuccessful ; the hernia coming down in five or six weeks. The 
many modifications of the plug of the instrument more recently introduced 
will doubtless lessen the cases of failure of the operation, which it would 
appear are not unfrequent. 

Case 5. Lateral dislocation of the head of the radius converted into 
the dislocation forwards and backwards. — Lieutenant L., IT. S. A., was 
thrown from a vicious mule on October 1st, '59, and received the weight 
of his body on his left hand extended before him. 

On visiting him half an hour after the accident, I found the elbow-joint 
very much swollen and so painful as to render a minute examination im- 
practicable. A prominence, however, could readily be felt on the anterior 
surface of the external condyle of the humerus ; the forearm was in a posi- 
tion about half way between pronation and supination, inclined rather more 
to the latter, and incapable of being either fully flexed or extended ; nor 
could this position be changed without causing extreme pain. He stated 
that he had a sensation of numbness in the thumb. 

Having in the course of an hour obtained the assistance of Surgeon 
Porter, he was put under the influence of chloroform, the parts having by 
this time become much more painful and greatly swollen. On making 
rather sudden flexion of the forearm upon the arm, a marked crepitus was 
for a moment distinguished, but no manipulation could again elicit it ; and 
at the same time it was observed that the projection over the outer condyle 
had disappeared, and the head of the bone was distinctly felt at the middle 
of the joint over the lower extremity of the humerus, and the motions of 
flexion and extension became still further impaired. Being now fully under 
the influence of chloroform, extension was made from the wrist, and the 
thumb at the same time pressed upon the head of the bone, when it returned 
to its place with an audible snap, only a slight exertion of force being re- 
quired. 

A splint was loosely applied to the forearm to maintain it in a fixed 
supine position, and cold lotions to the joint. 

The following day there was more swelling and an extensive vivid ec- 
chymosis around the joint. The swelling and ecchymosis gradually disap- 



44 



Clements, Notes of Surgical Cases. 



[July 



peared, and the splint was removed in the course of two weeks, and he soon 
regained the perfect use of the joint. 

The position of the head of the radius was first upon the front surface 
of the outer condyle of the humerus, and on the sudden flexion of the 
forearm made at the first part of the examination when he was under the 
influence of chloroform, it was carried upwards and inwards on to the 
lower part of the humerus, thus giving rise to the crepitus and to the pro- 
minence at the bend of the elbow. 

Case 6. Wound of the radial artery; compression; secondary hemor- 
rhage; ligature. — Of the- surgical aphorisms laid down by Mr. G. J. 
Guthrie, in his Commentaries on Surgery, none are supported with so 
much ability and enforced with such copious illustrations as those relating 
to wounded arteries. Commenting (page 221, Commentaries) on his 
aphorism that " no operation should be performed on a wounded artery 
unless it bleed," he adds, "unless the hemorrhage should be so severe or so 
well marked as to leave no doubt of it being from the main trunk of the 
artery itself ; nor is it then advisable to do so unless the artery continue 
to bleed. 11 

It is to suggest that the latter part of this rule is too broadly laid down, 
and is not the best applicable to the surgical treatment of certain arteries 
when wounded, that the following case is related : — 

November 21st, 1859. L , a workman in the Ordnance Department 

at Camp Floyd, Utah, aged about 23 years, was wounded by a piece of a 
large musket percussion-cap, which exploded, and was driven into the lower 
part of his right forearm, immediately over the radial artery. The wound, 
though small, was directly transverse to the course of the artery, and was 
immediately followed by a copious jet of hemorrhage, which was going on 
when he came to me. The piece of cap was felt with a probe at considerable 
depth, embraced by and imbedded in the tissues. It could not be removed 
through the existing wound, and with the view of tying the vessel if neces- 
sary, a short incision was made in the course of the vessel extending above 
and below the wound, and an irregular-shaped, sharp piece of cap removed.' 
On the extraction of the cap, the hemorrhage, which had come in a jet so 
marked as to make it certain the artery was wounded, ceased ; and though 
the wound was left open for half an hour, the muscles of the part thrown 
into action, and such gentle violence used as seemed justifiable, the bleeding 
did not recur, and, therefore, relying on the rule not to tie an artery unless 
it continues to bleed, I did not secure it by ligature, but brought the edges 
of the wound and incision closely together with adhesive straps, and ap- 
plied a compress and bandage up to the middle of the forearm. 

Two days afterwards, as he complained of pain in the part, I removed 
the dressing and found some redness extending several inches up the fore- 
arm, and the edges of the wound bathed with a little pus. Lead-water was 
applied, and in three days more the redness had disappeared, and the wound 
seemed nearly healed. 

On the 30th, nine days after the receipt of the wound, he intended to 
resume his work, but on rising suddenly from bed at an early hour of the 
morning, the wound commenced to bleed very freely. He came to me at 
once, and I found copious hemorrhage going on, which, however, was 



1861.] 



Clements, Notes of Surgical Cases. 



45 



easily restrained by pressure. He stated that a few days before a good deal 
of pus had come from the wound. I made an incision in the course of the 
artery in the line of the previous one, though longer, when the parts were 
found so thickened and agglutinated that, in the imperfect light of an early 
winter morning, I could not readily secure the vessel, though the bleeding 
point could be seen in the centre of an inflamed-looking mass ; and as the 
bleeding was easily controlled by pressure, I applied a compress and bandage, 
intending to ligate the vessel in the course of the morning when a better 
light could be obtained. 

Later in the morning the patient was seen in consultation with Surgeon 
Porter and Assistant Surgeon Getty. As the compress controlled the 
hemorrhage so effectually, it was then determined to continue its applica- 
tion, and in case this should fail or give rise to much swelling and inflam- 
mation of the arm (objections which were strongly urged against this 
treatment), that the vessel should be tied above and below the wounded 
point, where the tissues were more sound. Accordingly, a compress and 
bandage were carefully reapplied over the whole forearm. 

The following day he complained of a feeling of tension in the parts, 
and on the next the bandage was found wet with pus. 

On the 4th December, four days after the first recurrence of the bleeding, 
free hemorrhage again took place from the wound, late at night. On re- 
moving the dressing the wound bled very freely ; I placed a firm piece of 
dry sponge over the bleeding point and applied a bandage which controlled 
the hemorrhage, intending to ligate the vessel by daylight. 

In the course of the morning I proceeded to tie the artery in the presence 
of several medical officers. The forearm up to its middle was red and much 
swollen ; on pressure a half ounce of pus exuded from under the tissues 
about the wound, the seat of which was of a dark-ashy colour. After en- 
deavouring to secure the vessel at the wounded point, which was ineffectual 
owing to the disorganized condition of the part, I extended the incision 
downwards, but before the vessel could be found, very profuse bleeding 
occurred from a long surface in the tract of the wound, when I carried the 
incision upwards, and, after a tedious dissection, secured the vessel two 
inches above the bleeding points. This checked the hemorrhage but par- 
tially ; arterial blood continued to well out from the lower part of the 
wound ; the dissection, for such it was, was now continued below, and 
another ligature applied below the wound in the artery, when the hemor- 
rhage, which had been restrained by pressure, at the bend of the elbow, 
completely ceased. Notwithstanding the application of these ligatures, the 
pulsation of the vessel below the lower ligature could still be distinguished, 
and was doubtless caused by the current from the superficialis volse from 
the ulnar artery, which thus kept up the hemorrhage after the application 
of the first ligature, for on tightening the lower ligature all pulsation 
ceased above it on the cardiac side. 

The operation was exceedingly tedious ; the whole incision, which was 
4 J- inches in length, being through an undistinguishable mass of inflamed, 
swollen, and suppurating tissue, and the calibre of the artery itself exceed- 
ingly contracted. 

The wound gaped very much ; stitches were inserted above and below, 
and adhesive straps applied, but the edges could not be brought together, 
and the whole forearm was enveloped in lint kept constantly wet with ice- 
water. The following day the arm was less swollen, and on the succeeding 
day there was healthy suppuration in the wound, and the tissues were less 



46 Cleborne, Experiments with Asclepias Syriaca. [July 

infiltrated. On the fourth day after the operation the swelling had nearly 
disappeared, union was taking place, and the application of the ice-water 
was discontinued ; a slough was detached from the site of the original 
wound, it rapidly healed, the ligatures came away in due time, and the 
patient was discharged cured on December 26th, twenty -two days after the 
application of the ligatures. 

In this case it is seen that the artery was known to have been wounded 
at first ; a reliance on the rule of treatment quoted above led to the treat- 
ment by compression, which not only proved ineffectual, but also gave rise 
to a diseased condition of. the parts, which rendered the application of 
ligatures, ordinarily sufficiently simple, much more difficult and distressing 
to the patient than it would have been at first. 

In view of this case then the idea may be entertained, that when an 
artery is known to be wounded, and it can be secured by an operation 
which will not entail more risk than that of probable hemorrhage, it should 
be tied, even if it does not " continue to bleed ;" and this modification of 
Mr. Guthrie's rule may perhaps be most advantageously applied to arteries 
superficial in site, as the brachial in its whole course, the radial and ulnar, 
the posterior tibial near the heel, and others of less importance, in which 
it is not difficult to be certain whether or not the main trunk of the vessel 
itself be wounded. 

In these vessels no evils can arise from the obstruction of the current; 
the application of a ligature above and below the wound is ordinarily easy 
of performance, and destroys all chance of a recurrence of hemorrhage; and 
in this respect has special advantages in field operations with troops, where 
it is generally impossible to afford the attention and rest so indispensable 
in cases where ligatures have not been applied. 

Fort Faxjntleroy, New Mexico, February, 1861. 



Art. IV. — Experiments to determine the Effect on the System of the 
Asclepias Syriaca. By Christopher James Cleborne, M. D., As- 
sistant Surgeon U. S. K 

The Asclepias Syriaca has long been in use amongst the negroes of the 
south as a remedy for gleet, gonorrhoea, scrofula, &c, and is a common 
ingredient in many of the Indian cough nostrums of the present day. Em- 
pirics have extensively employed the root and other portions of the plant 
with more or less success. The most usual mode of administration is in 
powder or infusion, the latter, made by taking a small handful of the bruised 
fresh root, boiling it in four pints of water until it is reduced to three pints, 
and then adding a pint of whiskey; the last mentioned article is added to 



1861.] Cleborne, Experiments with Asclepias Syriaca. 47 



preserve it, and probably also to increase its diuretic properties. Old cases 
of gleet of many years' standing are reported to have been cured after other 
remedies had failed by taking a wineglassful of the infusion of the fresh 
root three times daily before meals. 

It occurred to me that it might be well to test its effects upon the system 
in health, when taken in the form and dose usually administered. I there- 
fore made an infusion of the dried root of the usual strength, and took it in 
the dose of a wineglassful three times a day (being at this time in perfect 
health). I continued its use for five days without observing any other 
effect than a slight sensation of nausea and an increased flow of pale- 
coloured urine which was of lighter specific gravity than usual. I increased 
the dose to a wineglassful four or five times daily, which produced, in 
addition to the effects before mentioned, vomiting and ardor urinas. 

An infusion of the fresh root, made of the same strength, had the same 
effects in a more marked degree, and in one-third of the dose of the infusion 
obtained from the dried root. I now determined upon making different 
preparations of the root, flowers, and other parts of the plant in order to 
test more fully the medical effects of each upon my own system. I ex- 
pressed a quantity of milky juice obtained from the fresh herb, and evapo- 
rated it slowly in a porcelain capsule over a water-bath at a low tempera- 
ture to the consistency of an extract ; this preparation was of a dirty 
colour, and disagreeable acrid taste. Of this I took at first three grains 
and gradually increased the dose up to five grains three times a day, when 
I had to discontinue its use on account of the excessive nausea, tickling 
sensation in the fauces, and a violent headache, confined principally between 
the eyes. Erom the flowers I made a watery infusion and evaporated it to 
the consistence of an extract which was exceedingly bitter and had but 
little of the properties peculiar to the rest of the plant. A fluid extract 
Was now prepared from the dried root by the following process : i£. — As- 
clepiadas syriacae contus. ^xvj (Troy) ; ether sulphurici fjiv ; aquae com- 
munis q. s. ; spts. vini rectif. f^x. Bruise the root fine so that it ban 
pass through a sixty sieve, pack in a percolator such as is used for 
preparing ethereal tinctures, &c, and moisten it with a menstruum of 
alcohol and ether f^vj of the former to f^iv of the latter, displace very 
slowly, and place the first tincture aside, then displace with the rest of the 
alcohol and water q. s. until the root is completely exhausted ; evaporate 
this in a porcelain capsule over a water-bath, then add the ethereal tincture 
and evaporate to one pint. This forms a preparation of a beautiful rich 
red colour, exceedingly bitter in taste and of an aromatic odor ; each fluid 
drachm representing an ounce (Troy) of the root. 

Having now a preparation of known strength, I began to try its effects 
upon the system, and accordingly on the 24th July, 1859, I took it in the 
dose of ten drops, gradually increasing the quantity until nearly Jij daily 
were taken in divided doses of 3ss with the following effects : — 



48 Cleborne, Experiments with Asclepias Syriaca. [July 

July 24, 10 A. M. Took ten drops of fluid extract asclepiados without 
any peculiar effects being observed. 

25th, 9 A. M. Took gtt. 10 in syrup, zingib. to disguise its disagreeable 
taste, and at noon took gtt. 10 more; this produced a decided increase of 
secretion from the kidneys. 

26th, 11 A. M. Took gtt. 20, at 2 P. M. gtt. 20 more; this produced an 
increased flow of urine, dizziness in the head (which lasted only a couple of 
hours), and a tickling sensation in the fauces. 

mh, 11 A. M. Took gtt. 30, and at half past 2 P. M. gtt. 20 more; this 
had the effect of producing increase of secretions of kidney, tickling sensa- 
tion at the end of the penis, uneasiness of stomach, slight inclination to 
evacuate bowels, severe headache, quick full pulse, 92 per minute. 

28th. I awoke with a severe headache, and a disagreeable feeling about 
the stomach, I therefore discontinued taking the medicine until the 30th. 

BOth, 12 A. M. Took gtt. 35 in cinnamon water, which in a few hours 
produced nausea, and an inclination to evacuate the bowels, slight pain in 
the stomach and diuresis. At 3 P. M. took gtt. 15, combined with tr. 
opium camph. gtt. v, and syrup, ginger. 3j- At 8 P. M. had a copious evacu- 
ation, soft consistence and brown in colour, accompanied by a slight pain in 
the bowels. The action of the heart seems to be increased ; pulse 98 per 
minute. 

3 1st Took gtt. 40 at 11 o'clock. This produced vomiting, leaving the 
system much relaxed and pulse feeble and frequent. 

Aug. 2. Took 5ss at 10 A. M., and at half-past twelve P. M. took gtt. 30 
with three drops of tr. opii ; this produced vomiting which was severe and 
long continued, leaving behind it a sensation of rawness in the stomach 
and a slight pain, coldness of surface of skin, feeble pulse, and a feeling as 
if some sharp instrument was thrust through from one temple to the other. 

Bd. Took at 9 A. M. gtt, 20 with gtt. xv tr. zingib. and gtt. 3 tr. opii. 
At 12 P. M. had an evacuation, soft in consistency and yellowish in colour; 
appetite much increased. I observed no other effects ; probably by this 
time the stomach had become used to the medicine, and its nauseating effect 
was not produced. The secretion of urine was normal ; pulse regular and 
there was no headache. 

I continued taking the fld. ext. asclepiados, gradually increasing the dose 
until the quantity taken amounted to 5iiss in 3ss doses three times a day, 
and at bedtime Jss combined with tincture of ginger and some aromatic water. 
As my health, and the circumstances in which I was placed would not 
allow of my experimenting upon myself further, I discontinued the medi- 
cine, it having occasioned violent vomiting, with retching, burning, and 
tickling sensations in the throat and fauces; stomach feeling painful and 
raw ; increased secretion of bile ; copious discharges from the bowels of soft 
fluid consistence, yellowish in colour and attended with some griping pain; 
headache; sense of constriction across the forehead, sometimes pain between 



1861.] Cleborne, Experiments with Asclepias Syriaca. 49 

the eyes ; excoriation of anus ; increased appetite. I prepared a fluid ex- 
tract from the fresh root, and by the same process that I have mentioned 
before in this paper. 

*lth. Took of this preparation gtt. 15 with tr. ginger. 3ss t. d. ; this pro- 
duced two pleasant copious evacuations, without pain or other unpleasant 
effects. 

Throughout these experiments the appetite seemed to be very much 
increased ; even after making a hearty meal a feeling of hunger would in 
the course of a few hours be again felt. 

I found that by taking 15 to 20 drops before breakfast, a gentle aperient 
effect was produced in the evening. 

The preparation made from the fresh root is nearly one-third stronger 
than that made from the dried root. An infusion of the root, or a decoc- 
tion made with water seems to take up its bitter taste with very little of 
its active principles. The infusion will not keep very long. 

The hard extract in the dose of from 3 to 5 grs. t. d. gradually increased, 
produces the same effects as the fluid extract ; it is made by evaporating 
the fluid extract down to the consistence of a hard extract. 

Anodyne, diaphoretic, emetic, stimulant, expectorant, and tonic effects 
have been ascribed to this root. Dr. Richardson, of Massachusetts, found 
the root possessed of anodyne properties. He used it in asthma, typhus 
fever attended with catarrh, &c, and found it to relieve pain, promote ex- 
pectoration, and relieve dyspnoea. (U. S. D.) I must say I did not ob- 
serve any anodyne effects produced by it in any of the doses mentioned in 
this paper. 

With all due deference to Dr. Richardson's statement, I think it is likely 
he employed some other plant, belonging to the genus, than the Asclepias 
syriaca that may possess the property he attributes to it. 

The effects of every dose were marked with particular care, and it did not 
in any instance act as an anodyne. It is a stimulant ; in my own case I 
found it increased the action of the heart. As an expectorant I can give 
no opinion about its effects, not having an opportunity to try it, though it 
has been favourably spoken of as such by many physicians. I do not think 
that it can be considered as a diaphoretic, at least not more so than other 
articles of mat. med. which produce a nauseating effect upon the system. 
That it is a purgative there can be no doubt. I have used it in many cases, 
and there are advantages which it possesses over many of the vegetable 
cathartics now in use. 

I consider it to be ionic, alterative, diuretic, purgative, emetic, in large 
doses, stimulant and anthelmintic. 

The following cases which have come under my notice prove that it is 
possessed of valuable medical properties well worth the attention of the 
profession. 

No. LXXXIII— July 1861. 4 



50 Cleborne, Experiments with Asclepias Syriaca. [July 



J. A. B., set. 30 years, had been suffering for some years with constipation 
of the bowels, pains in the right side and lower extremities, loss of appetite, 
&c. : gave him the following mixture : R. — Ext. fid. asclepiados §ss; Syr. 
zingib. ^iiss. M. ft. mist. Sig. — 3J twice daily, to be increased to a tea- 
spoonful three or four times daily. At the end of a month he felt much 
relieved, his bowels became regular, his appetite improved, to use his own 
words, "became almost too good for his means," and the pains in his limbs 
were entirely removed. 

H. Y. L., a young man of somewhat irregular habits, had been suffering 
from constipation of the bowels for over two years, being sometimes four 
or five days without a passage; he had used drastic cathartics, which he 
said, after their effects had been produced, made him much worse. He was 
also troubled with haemorrhoids. He took the fluid extract in doses of gtt. 
xx t. d. increasing the dose up to f3ss twice daily. He rapidly improved 
under this treatment ; his bowels have been open every two or three days, 
soft pultaceous stools being procured without any straining effort. The 
haemorrhoids disappeared by applying to them an ointment composed of 
R. — Acid, tannic. 3ss ; Ungt. glycerin, gj. — M. 

T. S., eet. 22 years, labouring under an attack of primary syphilis. On 
examination I found three good-sized chancres on glans penis, one on fre- 
num and one on each side of glans ; on each side an indurated syphilitic 
bubo. This patient was so susceptible to the influence of mercury that half a 
grain of any of its preparations would produce the characteristic effect upon 
him. 

I touched the chancre with sulphate of copper, dressed them with lint 
dipped in vin. aromat, applied pressure to bubo by means of a compress 
and bandage, and placed patient on a low diet of rye bread and buttermilk, 
and administered fid. ext. asclepiados gtt. xx three times daily, combining 
it with syrup of ginger and tinct. opii when it produced nausea. 

The patient, who had no appetite and was much debilitated, rapidly re- 
covered under this treatment ; his appetite returned ; the bubo disappeared ; 
the chancres cicatrized kindly ; the bowels were regularly moved once and 
sometimes twice daily ; his system gained strength, and in less than three 
weeks he had entirely recovered. 

An old case of dyspepsia of some years standing improved quickly under 
this treatment ; a diet of buttermilk and rye bread, and the following pre- 
scription. R. — Ext. fid. asclep. syriaca? 3iij ; Tr. nucis vomicae gtt. xxvj; 
Syrup, zingib. fjiiss. Misce et ft. mist. Sig. — 3j t. d. Buttermilk I be- 
lieve is very useful in many cases of dyspepsia ; it has the advantage over 
fresh milk of not constipating the bowels. 

Katy D , a child aged eight years, affected for some time with ascaris 

vermicularis ; she was much emaciated, and her system seemed completely 
broken down. I placed her on the rye bread and buttermilk diet, and 
gave internally ext. fid. asclepiados gtt. x t. d. and injected into the bowels 
3ij of the ext. in 8 oz. of mucilage of flaxseed. A large number of worms 
were discharged, and the child rapidly regained its strength. 

I have heard of other cases in which asclepias syriaca has been used as 
an anthelmintic and with great success. 

During the short time I was in the South, I had but little time to in- 
vestigate the properties of this drug ; but I entertain the hope that I shall 
soon have further opportunity to test more fully this valuable remedy. 



1861.] 



Nivison, Opium and Sulphate of Quinia. 



51 



Art. Y. — On the Antagonistic Effects of Opium and Sulphate of 
Quinia. By Nelson Nivison, M. D., of Hector, Schuyler County, K Y. 

That opium and quinia, when administered "simultaneously" as reme- 
dies, react upon each other, and to some extent countervail each other, 
is a fact which appears recently to have arrested the attention of numerous 
observers. Though we are prepared to admit that in a qualified sense they 
are " antidotes to each other" each neutralizing the bad effects of the 
other, we cannot subscribe to the rule lately laid down by Dr. Gubler, that 
"they ought not to be administered simultaneously." 1 

We claim, on the contrary, that it is precisely in virtue of the fact that 
these remedies do react upon each other when simultaneously administered, 
that the happiest therapeutic results are often produced, differing essentially 
from the separate action of either. 

So true is this, so important the principle involved, so extensive its range 
of application, so certain and satisfactory the results, that it is believed 
that few of the recent improvements in practical therapeutics, have added 
more largely to our resources than that derived from the combined action 
of these remedies. 

At the present time, perhaps no two remedies enter more largely into 
the general therapeutics of this country than the preparations of bark and 
opium. There is scarcely a disease in which their virtues have not been 
tested, often by many and able observers. Some of their properties have 
been determined with a certainty that amounts to absolute demonstration, 
others have now won the confidence of a majority of the profession, while 
other claims put forth with- equal assurance have as yet failed to secure 
that confidence which a frequent use would necessarily imply. 

Under such circumstances, any investigation which promises clearer 
light in regard to the properties and remedial effects of agents so powerful as 
these, can but be a matter of interest, not alone to the medical philosopher, 
but especially to those who assume the practical duties of the healing art. 

Before proceeding to the discussion of the conjoint action of opium and 
quinine, it may be well to notice some of the phenomena produced by their 
separate action. 

Perhaps we cannot give the general and more obvious effects of opium 
better than to quote Dr. Gubler. He says: "Opium carried into the circula- 
tion induces a particular excitement, gives volume to the pulse, exalts the 
temperature, augments the capillary injection of the skin, and excites dia- 
phoresis." To this we may add that while operating thus on all parts of 
the system it is sometimes directed with peculiar force to the brain, often 
producing intoxication or delirium. This is usually followed by an agreea- 
ble mental placidity, and soon all consciousness is lost in sleep. 

1 Journal des Connaissances Med. et Pharmaceutique, Aug. 30, 1858. 



52 Nivison, Opium and Sulphate of Quinia. [July 

With Dr. Gubler, we will say of quinia that its effects on the circulation 
are inversely to those of opium. It gives tone, or contractility to the capilla- 
ries, and thus overcomes congestion. It is anti-periodic and sedative. As 
incidents of its operation, we have various phenomena which indicate that 
it often produces great disturbance of the nervous centres. 

But no mere outline of this character will give to the inquiring student 
an adequate idea of either the modus operandi, the physiological, or the- 
rapeutic effects of these articles. 

'Tis the latter only which, on the present occasion, chiefly interests us. 
And it is only by studying their relation to certain pathological conditions 
that we shall be likely to arrive at a definite understanding of them. 

Of their physiological effects we will simply say that both opium and 
quinia have a powerful affinity for the nervous system, each impressing it 
in a manner peculiar to itself and through its agency modifying the action 
of every organ in the performance of its function. Whether, as has been 
assumed, opium acts through the cerebro-spinal, and quinia the ganglionic 
system it is not now our purpose to inquire. 

That quinia has a powerful affinity for the nervous system we think 
will hardly be questioned. If any doubt should exist, the fact, we con- 
ceive, admits of demonstration. It is a law of the animal economy that 
no function can be performed without loss of substance. Muscular motion 
implies a loss of fibrin, and any activity of the brain and nervous system 
involves a corresponding metamorphosis of their tissues. The waste of 
nerve-tissue, or, in other words, the activity of the function of innervation, 
is easily calculated, being in a direct ratio to the sum of the phosphates 
found in the urine. 

From carefully conducted experiments it appears that quinia given in a 
state of health augments the amount of the phosphates, and consequently 
increases nervous action. 

But it is in morbid states of the nervous system that the more striking 
effects of quinia are exhibited. Dr. Ranke {Med. Times and Gazette, 
May 30th, 1857), while conducting a series of experiments for determining 
the effects of ague and quinia on the urine, ascertained that the paroxysm 
of fever greatly increased the amount of phosphoric acid. Showing most 
clearly that the nervous system plays an important part in the paroxysm 
of ague. Dr. Hammond {American Journal Med. Sciences) found, while 
experimenting on himself during an attack of intermittent, that, on the 
day of the first paroxysm, the amount of phosphoric acid found in the 
uriue was 69.18. Next day (intermission), 52.95. Third day (paroxysm), 
72.95. Fourth day (intermission), 55.27. On this day, quinia was ad- 
ministered. The next day, being the one for the paroxysm, and when the 
amount of phosphoric acid, calculating from the average of the preceding 
days, would have been 71.06, it fell to 56.22 — but a trifle above that 
excreted on the days of intermission. 



1861.] 



Nivison, Opium and Sulphate of Quinia. 



53 



But rapid disintegration of nerve-tissue is not confined to intermittents. 
It is usually a prominent element in nearly all the severer forms of fever. 
The general debility and non-performance of function are, doubtless, due to 
this cause. Continued experiment led Dr. Hammond to the conclusion that 
" Quinia has the power to prevent much of this great waste of nerve-ma- 
terial." We will add that it not only prevents destruction of nerve-tissue, 
but, by its well-known effects on the function of nutrition contributes greatly 
to the reparative process. It may, therefore, be justly entitled a great 
conservator of the nervous system in conditions of febrile excitement or 
nervous prostration. 

But the influence of quinia is not confined to the nervous system. It 
has important relations to the circulation, and the character and quality of 
the blood. Headland believes " that its action is exerted primarily on 
the blood and not on the nerves." We will not discuss that question on 
the present occasion, nor is it necessary to our present purpose. All the 
vital functions are so intimately connected that no one is independent of 
all the rest. 

The more obvious and important effects of quinia will alone be noticed ; 
and, among these, none is of so much importance, as its power of giving 
contractile action to the capillaries. 

This power appears to extend to all parts of the capillary system. Dr. 
Corrigan, Physician in Ordinary to the Queen in Ireland, says : " Quinia 
appears to possess the same power in giving contractility to the capillaries 
in the lungs which we know it to possess in so marked a degree over the 
capillaries and venous radicles in the spleen." 

This property of quinia gives us a power, over almost all forms of ve- 
nous and capillary congestion which, perhaps, it is impossible to obtain by 
any other known agent. 

Another effect of quinia on the circulation is that of approximating the 
frequency of the pulsations to the healthy standard, when much too frequent 
or much too slow. 

We may incidentally mention that quinia enters the bloodvessels, and 
goes the rounds of the circulation. Tiecleman and Gmelin found it long 
ago in the blood of a patient to whom it had been administered, and if we 
needed jfurther confirmation, we have it in the fact that in from three to 
twelve hours after its administration it will appear in the urine. Dr. Bence 
Jones, M. Briquet, and many other authorities might be quoted on this 
point. 

Quinia not only influences the circulation, but it works important 
changes in the character of the blood itself. We have already had occasion 
to notice its influence on the phosphates. Its action in diminishing the 
amount of uric acid is still more striking. Dr. Ranke experimented on 
three healthy individuals. He found that under the influence of quinia 
the amount of uric acid was reduced nearly one-half. Dr. Hammond made 
a series of observations during an attack of intermittent fever, where, as in 



54 Nivison, Opium and Sulphate of Quinia. [July 

all fevers, the amount of uric acid is always greatly increased. Here, like- 
wise, the quantity was promptly reduced more than half by the action of 
quinia. 

But perhaps the most remarkable effect of quinia on the blood is the 
fact that it defibrinates it, and renders it fluid and incoagulable. This fact, 
mentioned by Dr. Samuel Gordon in the Dublin Quarterly for August, 
1856, and clearly established by the experiments of Baldwin, Melier, Bri- 
quet, and other responsible authorities, may throw some light on its action 
in preventing and overcoming congestion, and subduing many forms of in- 
flammation. 

The diseases to which quinia is specially adapted usually contain an 
important neuropathic element. The innervation may be either deficient, 
irregular, or excessive ; all, however, imply the existence of, or ultimately 
produce nervous debility. Many derangements of circulation, nutrition, 
secretion, sensation, and muscular motion, are included as sequela?. An 
example of excessive innervation is manifest in precocious children. The 
vivacity, intellectual and moral development indicate a degree of nervous 
activity altogether dispro portioned to the restorative or nutritive function. 
Early decay is the result. 

The diseases accompanied with derangement of circulation are attended 
with general or local congestions. Conspicuous among them are the in- 
termittent, remittent, continued, and pernicious fevers, and many diseases 
usually regarded inflammatory. Derangements of secretion, excretion, and 
calorification, follow in the train of disordered circulation, and imply dis- 
turbance of the ganglionic system. 

Quinia is also adapted to many diseases originating in the cerebro-spinal 
system, as chorea, neuralgia, &c. ■ 

Of the general properties of opium, the "antagonist" of quinia, we 
shall speak very briefly. 

One of the most important properties of opium is that of a general 
stimulant to the vital powers. Says Mr. Skey, the eminent Surgeon of St. 
Bartholomew's Hospital : " There is no drug, simple or composite, known 
to our pharmacologists, that possesses an equal power with opium in giving 
energy to the capillary system of arteries, of promoting warmth, and thus 
maintaining an equable balance of the circulation throughout the body." 

This property of opium, that of equalizing the circulation, is an invalu- 
able one. There is scarcely a pathological condition in which it is not de- 
sirable, and without this agent sometimes difficult or impossible to obtain. 

Opium not only accelerates the circulation when it is feeble, but it mode- 
rates it when excessive. This may appear paradoxical, but we think it 
admits of a ready solution. The circulation is subservient to innervation. 
While the nervous system maintains its tone, the disturbing cause must be 
very considerable or long continued, or the circulation will remain uninflu- 
enced. When in an atonic condition, very slightly irritating or exciting 
causes will hurry the circulation. We believe a rapid pulse always implies 



1861.] Nivison, Opium and Sulphate of Quinia. 55 



deficient innervation. Opium is a direct stimulant of the nervous system ; 
it supplies for the time being the necessary power of resistance to the nerv- 
ous centres, the effect of the disturbing cause is neutralized, and the circu- 
lation regains its equilibrium. 

Another remarkable property of opium is the effect it has over the 
nutritive or reparative function. We see illustrations of this in the fact 
that old ulcers which have resisted all other means of treatment will readily 
heal when the system is brought under the influence of that drug. Its 
effects on obstinate chancres, senile gangrene, chilblains, &c, are examples 
in point. 

A point that demands a passing notice is the general derivative effect 
of opium. By determining to the surface, internal parts are relieved of 
undue accumulations. In this way we can often spare the system the irri- 
tation and exhaustion that would result from counter-irritants. 

We will mention still another point of great practical value, and that is 
the property which opium possesses of retarding the too rapid metamor- 
phosis of the tissues. This enables us to maintain the integrity of the 
organism in exhausting fevers, wasting discharges, long-continued exposure 
to cold, or any protracted mental or physical suffering. 

The more familiar effects of opium in removing pain, allaying irritation, 
procuring sleep, &c, we have not space here to notice. Enough has been 
written, we trust, to render it apparent that a multitude of pathological 
conditions demand the benefit of its influence. It is not only adapted to 
the inert condition of the remote vascular system, but it subdues active 
inflammation, and acts as a true life-sustainer when we are compelled to 
meet the protracted suffering incident to our frail mortality. 

It is obvious that each of these "antagonistic" remedies of Dr. Grubler 
has a wide range of application. But the question arises : Can the several 
effects that we have imputed to them be confidently relied on when admin- 
istered in the several pathological conditions that we have indicated? 
We readily admit many and various exceptions ; but we claim that the num- 
ber of these exceptional cases will be greatly reduced when the two remedies 
are given simultaneously. - 

Some of the exigencies demanding a combination of these remedies will 
now be indicated. 

1st. There are many acute inflammatory conditions that will promptly 
yield to the influence of full doses of opium, where those doses cannot be 
given without the risk of so far paralyzing the nervous energies as to induce 
fatal congestions. We have seen that quinia possesses pre-eminetly the 
power of giving contractile action to the capillaries, and thus overcoming 
congestion ; and experience has amply demonstrated that if the proper 
amount of this be combined with the opium in the class of cases above 
referred to, as much of the latter may be safely administered as may be 
requisite to produce the effect desired. 

2d. A frequent objection to the free use of opium is its tendency to so 



56 Nivison, Opium and Sulphate of Quinia. [July 

far reduce the biliary and renal secretion as to incur the risk of fatal tox- 
aemia. Combined with quinia this tendency is to a great extent counter- 
acted. 

3d. Opium frequently reduces the respiratory action to such an extent 
that we are liable to have all the evils incident to imperfectly aerated 
blood. If, under these circumstances, we invoke the "antagonistic" effects 
of quinia, these unpleasant consequences are usually averted, while all the 
desirable effects of the opiate are retained. 

4th. The after effects of opium are frequently so unpleasant as to neu- 
tralize or perhaps overbalance all the good that would otherwise result. 
These usually do not appear when the remedy is administered in combination 
with quinia. 

5th. In many cases of extreme exhaustion, such as follows protracted 
hemorrhages and other like debilitating causes, we can temporarily arouse 
the energies of the system by the free use of opium ; it is in fact the sheet- 
anchor; often the only hope. When the sensibilities of the system are 
thus reduced, the toleration of this drug is often truly astonishing. Under 
these circumstances, however, it not unfrequently happens that the quantity 
which is barely sufficient to produce the reaction is yet sufficient when it 
does occur to produce unpleasant narcotism. If in these cases we give 
quinia with the opium, we not only secure the desired action with a less 
amount of opium, but the more protracted operation of the quinia will 
enable us to maintain the reaction for any desired length of time without 
those frequent repetitions of the opium that would otherwise be necessary. 

We may mention in this connection that persons who from accident or 
design have taken overdoses of opium and are found in a state of narcotism, 
are often promptly aroused by the administration of a full dose of quinia, 
This is especially the case in young children, who usually tolerate opiates 
very badly. 

6th. Many patients from idiosyncrasy cannot take opium. When given 
in combination with quinia a large proportion of these persons take it 
without inconvenience. 

We might multiply these examples were it necessary; but if we are thus 
far correct, quinia is a valuable adjuvant and often corrects the unpleasant 
effects of opium. 

It may perhaps serve to illustrate the foregoing propositions to state 
that other agents than quinia, as the peculiar mental condition of lunacy, 
the continued effect of cold, &c, will sometimes neutralize the bad effects 
of opium without impairing the good ones. Mr. Skey being obliged to 
ride all night in December when he had forgotten his overcoat, says : "After 
riding ten miles I took twenty-five drops of laudanum, and rode the remain- 
der of the night without inconvenience." He says, it may be asked "What 
was the effect on the following day?" and replies, "None whatever. The 
cold and the opium mutually balanced each other; there could be no reac- 
tion, for the duration of the cold exceeded that of the opium." 



1861.] Nivison, Opium and Sulphate of Quinia. 57 



I am inclined to think the action of the quinia in this regard analogous 
to that of the cold. The duration of its action generally exceeds that of 
the opium, thus supporting the system till the effects of the opium shall 
have passed away. 

On the other hand, certain well-known effects of quinia are often de- 
sirable where, from peculiarity of circumstances, we either cannot obtain 
them, or, doing so, we bring with them such an undesirable train of con- 
comitants that we are forced to dispense with the article altogether. We 
will notice a few of these peculiarities very briefly. 

1st. The prominent feature of many diseases is dangerous congestion of 
some internal organ or organs. Here the well known action of quinia in 
giving contractility to the capillaries of congested parts is exceedingly 
desirable; but where, on trial of the remedy, we find we have imparted only 
a peculiar excited action to the general circulation, under the influence of 
which the congestion is aggravated rather than relieved. The addition of 
a sufficient amount of opium to control this excitement will not only insure 
the legitimate operation of the quinia on the capillaries, but by diverting 
the general circulation to the surface, aids still further in overcoming the 
congestion. In this class of cases either opium or quinia acting alone 
would almost certainly add to the existing congestion ; in combination the 
bad effects are neutralized, and the two remedies co-operate in producing 
the desired relief. 

2d. There are many forms of inflammation to which, mutatis mutandis, 
the above remarks will apply with equal force. Judicious combinations of 
the remedies in question will often give us the most perfect control of the 
vital forces, and enable us to fulfil the various indications in the most satis- 
factory manner. There are many points of interest involved in this branch 
of our subject, in the discussion of which the limits of our article forbid us 
to enter. (For much that is valuable on the points here involved we refer 
to the Dublin Hospital Gazette for July, 1856, and the Dublin Quarterly 
for August of the same year.) 

3d. There is another great class of diseases in the treatment of which 
quinia is almost indispensable. I allude to the idiopathic fevers. Here 
also we are liable to have various disturbing symptoms demanding the use 
of opiates. Experience has demonstrated that they may be combined with 
quinia with the most beneficial results. 

4th. There are various affections usually denominated neuralgic, which 
are palliated by opiates and sometimes cured with quinia. These cases 
will often yield more speedily to the combined influence of opium and 
quinia than to any other known remedies. 

5th. There are numerous morbid conditions belonging to the neuroses, 
often associated with anemic states of the system where the true etiology of 
the disease can doubtless be traced to defective nerve nutrition. We have 
already had occasion to notice the action of both opium and quinia in 
modifying and improving the function of nutrition. In the present state 



58 



Alder, Yesico-Vaginal Fistula. 



[July 



of our knowledge there is nothing that would preclude the idea that this 
improved nutritive action may extend to the nerve tissue. But whatever 
the rationale, the fact remains that very many of these neuropathic condi- 
tions will yield to the combined action of these remedies. 

We are forced to the conclusion that opium and quinia are not so far 
" antagonistic that they should never be administered simultaneously," as 
maintained by Dr. Gubler. 



Art. YI. — Three Cases of Vesico-Vaginal Fistula, successfully treated 
by Sims' Method. By J. Mercer Adler, M. D., of Davenport, Iowa. 
(With five wood-cuts.) 

Case I. The entire history of this case is interesting; the writer is 
acquainted with all the circumstances connected with it. The patient, 
Joanna B., setat. 21, was taken in labour with her first child on Tuesday, 
May 22d, 1860. She is a woman of below the ordinary stature, compactly 
built, and of sanguine temperament. The labour progressed slowly until 
Thursday, the 24th, when the regular medical attendant was called. On 
Friday, the 25th, at noon, I was called in consultation with Dr. M'Cortney 
to see her. The child was dead. The head was impacted in the pelvic 
cavity, the vertex presenting at the vulva. The cause of the obstruction 
to delivery was found to be too great curvature of the coccyx, which we 
subsequently learned to have been the result of a fracture of the bone from 
a fall in early life. Craniotomy was at once decided upon, and the child 
was extracted with the blunt hook introduced into the foramen magnum. 

The woman subsequently did well. In a week she was up attending to 
her household duties. On Thursday, June 21st, while at work, she sud- 
denly felt the urine trickling from the vagina. Up to this time she had 
regularly passed the urine without inconvenience, but having a slight diar- 
rhoea in the morning, accompanied with some tenesmus, she attributed the 
difficulty to her straining while at stool. On visiting her the day following 
with Dr. M'C, and making an examination of the vagina, we found an 
extensive slough three-fourths of an inch in length by nearly half an inch 
in width, in the vesico-vaginal septum, its long diameter being transverse. 
The slough had only partially separated and could not be detached. 
The entire surface and edges were freely cauterized with nitrate of silver, 
a curved catheter introduced, and the patient put on her back, in the hope 
that as the slough separated, the granulating surfaces might repair the 
breach of substance and the opening be closed. This treatment was fol- 
lowed from day to day, but the slough finally separated, leaving an irre- 
gular hiatus about three-fourths of an inch in length by half an inch in 
breadth, its anterior edge semicircular, the posterior one irregular and 
wavy in outline, above the edge of which the mucous membrane of the 
bladder protruded. The case was evidently one to be remedied only by an 
operation, with a view to the preparation for which, the parts were occa- 
sionally touched with the caustic, well cleansed, and the patient's general 
health improved. 

The case is remarkable so far in this respect, that the patient should have 
been going about, attending to her duties daily with such an extensive 



1861.] 



Alder, Vesicovaginal Fistula. 



59 



amount of disorganization of the tissues of the vagina in progress, without 
being conscious of any uneasiness. The sloughing was doubtless the result 
of the long-continued pressure of the child's head against the pubic arch, 
causing arrest of circulation and consequent destruction of the vitality of 
the tissues. It may here be stated that during the whole time of labour 
the woman regularly evacuated the contents of the bladder. 

On Saturday, August 4th, assisted by Drs. Witherwax and M'Cortney, 
the following operation was performed : the bowels had been well moved 
the evening previous. The woman being placed in position, and the specu- 
lum of Sims introduced, a silver catheter was passed into the urethra 
and pushed firmly against the fundus of the bladder so as to bring it as 
much on the stretch as possible and retract the protruding mucous mem- 
brane. The posterior edge of the fistulous opening being caught in the 
middle by a strong pair of toothed forceps and well lifted up, the point of 
a curved knife was thrust in under the hold of the forceps at the edge of 
the mucous membrane of the bladder, and brought out about a quarter of 
an inch beyond in the vaginal mucous surface. The edge of the knife 
was then steadily pushed along with a sawing motion, the hold of the for- 
ceps being changed occasionally so as to bring the parts on the stretch, 
until the corner or angle of the fissure was reached. The same process 
was repeated on the other side, and in a few minutes the edges were thus 
easily and thoroughly pared. The angles were clipped out with the curved 
scissors. A wad of linen wet with cold water was then introduced into the 
vagina and the patient laid on her side. In about ten minutes, all hemor- 
rhage having ceased, three silver sutures were introduced and brought toge- 
ther. The apposition of the edges being satisfactory, the process of twisting 
the sutures to their places was performed. In twisting the one on the left 
an unfortunate accident occurred. Either from an imperfection in the wire, 
or from its being twisted too tightly, it gave way close to the loop of the 
suture. Fearing that it might possibly give way (although it held its 
place), an additional suture was introduced. The ends of the wires 
were brought together outside the vulva, secured in a piece of tape, and 
confined to the thigh. The whole time consumed, from placing the woman 
on her knees to the introduction of the catheter after she was placed on 
her back in bed, was just one hour. The catheter being introduced, half a 
teacupful of bloody urine escaped, but it soon became clear. Half a grain 
of morphiae suiph. was administered and the patient left for the night, with 
directions to remove the catheter and wash it every two or three hours. 

The patient passed a comfortable night, and during the following four 
clays did well. The catheter was withdrawn every three or four hours 
and washed with diluted muriatic acid to prevent its being filled by the 
phosphatic deposit, which was quite abundant. On the fourth night and 
morning of the fifth day the patient suffered from severe headache, pains in 
the abdomen, nausea, and vomiting. Her condition became so alarming, 
apparently resulting from the want of action of the bowels, that it was 
deemed necessary to administer injections to move them. These were re- 
peated several times without success. A bottle of solution of citrate of 
magnesia, well iced, was then given. It acted freely, and at once relieved 
the distressing nausea and headache. Subsequently there was no trouble. 
At the expiration of the ninth day an examination was made, and the union 
appeared perfect. Two of the sutures were removed. The remaining two 
were so deeply buried in the tissues that they were left until the following 
day. On the tenth day everything appearing firm, they were removed with 



60 



Alder, Yesico-Yaginal Fistula. 



[July 



some difficulty from their imbedded positions, and we were gratified to 
behold a most perfect success. N 

The line of cicatrization was broad and firm, curved in outline to corre- 
spond with the anterior lip of the fissure. The bowels were moved by an 
enema, and directions given to remove the catheter every two hours for fif- 
teen minutes at a time, during which the patient was to lie on the side. 
Her back was rubbed with spirits, the vagina syringed, the vulva well 
cleansed, and the slight abrasion of the internal labia powdered over with 
oxide of zinc. The catheter was from day to day suffered to be withdrawn 
for a longer time. 

On the thirteenth day after the operation it was allowed to be with- 
drawn two hours at a time, and at the first effort to pass water without 
the catheter it flowed freely. From this time it was not again introduced. 
On the fifteenth day an examination was made ; the vagina was found 
perfectly healthy in appearance, and the only trace of the fistulous opening 
left was a firm, solid cicatrix. 



Fig. 1. 



Case II. On Tuesday, February 6, 1860, in company with Dr. P. Gregg, 
of Rock Island, Illinois, I visited Mrs. J. H. S., of Henry County, Illinois, 
with a view to an operation for her relief. On introducing the speculum 
of Dr. Sims, a most deplorable sight presented itself for our contemplation. 
From a point beginning about an inch from the meatus urinarius up to the 
os uteri there was an irregular oval hiatus, three and a half inches in length, 
and varying from one to two inches in width, through which a view was 
afforded of the entire cavity of the bladder. On the right there remained 
a considerable part of the vaginal septum, its edge ragged and partly cica- 
trized ; on the left and above, the mucous membranes of the bladder and 
vagina seemed almost continuous, separated only by a broad line of cicatri- 
zation which finally lost itself in the cervix uteri. All support from the 

attachment of the vagina to the anterior 
segment of the cervix being lost, the os and 
cervix fell into and blocked up the fundus of 
the bladder. 

An approximate idea of the appearance 
and extent of the fissure may be obtained 
from the accompanying figure (Fig. 1, one 
third the natural size), for the general out- 
lines of which and method of representation 
I am indebted to the excellent drawings of 
Dr. Bozeman, accompanying his paper on 
the subject of Yesico-Yaginal Fistula?, iV. A. 
Med.-Chirurg. Review, vol. i. page 576. 

The case appeared to be an unpromising 
one, but, urged by the great anxiety of the 
patient, and having in our subject a young 
woman in perfect health, of strong and well- 
developed muscular fibre, cheerful disposition 
and regular habits, we determined to attempt 
an operation, and decided upon the following 
plan of procedure : First to unite the edges 
as far up as possible by transverse sutures, 
and subsequently, if in this we succeeded, to 
unite the triaugular edge of the septum with the anterior lip of the os uteri. 




1861.] 



Alder, Vesico -Vaginal Fistula. 



61 



The patient being placed in position, the process of paring the edges 
was begun at the point a (Fig. 1), and carried on continuously around as 
far as the point (c), leaving a broad bevelled edge pared nearly to the ex- 
tent of half an inch in width. From the point (c) up to the cervix a deep 
groove was made in the tissues with a spade-shaped knife, being guided in 
making it by the line of cicatrization. The operation of paring the edges 
was tedious and painful, the hemorrhage being considerable and much ob- 
scuring the view. A large soft sponge was introduced into the parts, 
and the patient allowed half an hour's rest. Strong silver wire sutures 
were introduced at intervals of nearly half an inch. The points were 
carried full half an inch from the edge of the mucous membrane of the 
vagina, and as nearly as possible through at the edge of the mucous 
membrane of the bladder, and brought out at corresponding points on the 
opposite side. The introduction of the needles above was extremely diffi- 
cult and tedious, requiring much manipulation on account of the contracted 
space afforded by the transverse field of the speculum. 

Anticipating as we did a great amount of traction and strain upon the 
remnant of the septum, we deemed it best to introduce but seven sutures, 
and to include within the loop of each as much of the tissues as pos- 
sible. The operation was much facilitated 
by moving the speculum from side to side, so Fig* 2. 
as to expose only one edge of the fistula at a 
time. The loops of the sutures when re- 
moved measured from an inch to an inch 
and a half in length each. 

After a rest of half an hour, the parts 
were well sponged and cleansed, and the su- 
tures twisted firmly to their places by means 
of the ingenious little instrument of Dr. 
Coghill (Figs. 2 and 3). The ends of the 
wires were twisted together and confined in 
the commissure of the thigh and vulva by a 
piece of tape passed round the thigh, The 
patient was placed on her back, and the sig- 
moid catheter of Dr. Sims introduced, through 
which flowed several spoonfuls of bloody urine 
with bubbles of air. The patient was left in 
the care of an experienced nurse, with proper 
directions as to the management of the cathe- 
ter ; a light diet enjoined, and sulphate of 
morphia to be administered to allay restless- 
ness or check any disposition to evacuate the 
bowels. 

Dr. Gregg visited her on the 8th; found 
her suffering from nausea, attributed to the 
morphia which she had taken. The urine, 
mixed with mucus and blood, continued to 
pass through the catheter and required its A 
frequent removal. Dr. Gr. visited her the ¥ 
following day. Notwithstanding all precau- 
tions, her bowels had acted freely the night before. The urine flowed 
through the catheter with less hindrance. She was then left undisturbed 
until the 16th. 




62 



Alder, Yesico-Vaginal Fistula. 



[July 



Fig. 4. 




The result of the operation may be perceived by a glance at Fig. 4. The 

parts had failed to unite at the point (a), 
where there remained an opening as large 
as a bean, and above there was a large 
fissure bounded by the cervix uteri and 
the edge of the septum. This fistula 
appeared about an inch in length, and 
nearly of equal width. 

Our operation had succeeded beyond 
expectation, and we were well pleased 
with the result. 
b On the 20th of March we again visited 
the patient, with the object of closing 
the lower opening (a, Fig. 4), preferring 
to complete the first stage of the proce- 
dure before attempting the closure of the 
upper fistula, one border of which was to be 
formed of the anterior lip of the os uteri. 
The operation was performed with three 
sutures introduced somewhat obliquely, 
and the patient was left with the customary 
directions for management. The sutures 
were removed on the 28th, union being 
perfect. The bowels were thoroughly 
evacuated by a dose of castor oil and an enema. Directions were given to 
draw off the urine every hour or two until the sphincter vesicas recovered 
its tone, and she was able to pass water at will. She was soon able to be 
up, and retained the urine three or four hours at a time without uneasi- 
ness. April 9th was appointed for the final operation. 

On making an examination the cicatrix appeared firm, and the entire 
parts presented a healthy and natural look. The cicatrix measured two 
and a quarter inches in length ; it had contracted much, however, the 
line of coaptation of the edges at the first operation having been full three 
inches in length by actual measurement. An unexpected obstacle here 
presented itself, precluding the possibility of completing our operation as 
proposed. The cervix uteri was so completely incarcerated in the bladder, 
and so firmly held in its place there, that it was found impossible to lift it 
out, so as to form union with the anterior lip of the os. The body of 
the uterus was so much retroverted that all our attempts to introduce a 
sound into the uterine cavity, in order to lift the organ from the bladder, 
proved unsuccessful. In this emergency the simplest and easiest solution of 
the difficulty was to form union with the posterior lip, and thus imprison 
the os permanently within the bladder ; an operation also very acceptable 
to the wishes of the patient from the fact of its precluding the possibility 
of the occurrence of- pregnancy. The operation was, therefore, thus per- 
formed, five sutures being introduced. The sutures were removed April 
16th, the parts having failed to unite. 

The condition of the patient and subsequent events fully accounted for 
the failure. The confinement from the previous operations, and the reten- 
tion of the secretions in the prima via of a person of active and regular 
habits, was followed by great derangement of the entire nervous system. Ob- 
stinate constipation ensued. A slow irritative fever, with delirium, succeeded 
— the consequence of the absorption of vitiated secretions. The patient was 



1861.] 



Alder, Vesico-Yaginal Fistula. 



63 



much debilitated and depressed ; but under the judicious and vigilant care of 
her accomplished medical attendant, Dr. Gregg, she soon recovered. In May, 
the menstrual functions resumed their activity, and the patient menstruated 
through the bladder. Her condition was quite tolerable. The urine was 
retained without difficulty two or three hours while walking about — the 
uterus acting as a plug above, and blocking up in some measure the escape 
of the urine. 

November 8th, the fistula was again closed with four sutures, and a 
minute opening (c, Fig. 4), discovered there for the first time, was also 
closed with a single suture. This minute fistula was doubtless formed by 
the dragging of one of the sutures in the first operation. The treatment of 
the patient was the same, with one exception, a plan adopted from the 
result of experience derived from the management of the first case here re- 
ported. Instead of giving opiates to restrain the action of the bowels, an 
enema was administered on the 10th, which, not operating, was followed 
by a dose of castor-oil. The bowels were freely moved on the 10th, 13th, 
14th, 15th, and 16th, without the slightest unfavourable result, the patient 
being gently inclined to the side, the catheter retained in situ, warm ene- 
mata administered, and a bed-pan slipped under the buttocks. During the 
nine days of confinement her diet consisted of light, nutritious animal 
broths, &c. The sutures were removed on the 17th, union being complete 
and perfect. The tone of the bladder was soon restored, and in a few 
days the patient was about her household duties, entirely and perfectly 
cured. 

On the 26th of December, we received from her husband the astounding 
intelligence that the woman was pregnant I Though almost incredible to 
us, still the evidence was so positive that we could not doubt the existence 
of the fact. The husband stated that for some days she had felt the motion 
of the foetus, and that on the 25th, while walking about the house, she 
had felt certain violent movements, which were immediately followed by a 
recurrence of the leaking. On the 1st of January, while we were preparing 
to make a visit to the patient to verify the 
truth of the information we had received, and Fig. 5. 

to determine what would be best to do under 
the circumstances, we received word that the 
woman had aborted. On visiting her a few 
days subsequently, we were informed that she 
had been suddenly seized with labour-pains, 
and that the foetus was born in two hours, 
having reached apparently the end of the fifth 
month. The patient had menstruated in May 
and June, and had probably become pregnant 
after the latter month, impregnation having 
taken place through the fistulous opening. 

The destruction of the septum was much less 
than we anticipated, the laceration having oc- 
curred lower down than the site of the recent 
opening, and being of an irregular curved shape 
(see Fig. 5), one and one-fourth inches in 
length by three-fourths of an inch in width. 
This opening was closed January 28th, by six 
sutures, two transverse, two longitudinal, and 
two oblique. 




64 



Alder, Yesico-Yaginal Fistula. 



[July 



An enema was directed to be administered on the 30th, and repeated 
every second day. On Monday, February 4th, the seventh day after the 
operation, the patient began to menstruate, requiring the removal of the 
catheter, which was not again introduced, she being able to void the con- 
tents of the bladder at will. The sutures were removed on the 6th of 
February, exactly one year from the date of the first operation, the parts 
being perfectly sound, union complete, and most satisfactory in every 
respect. The patient got up immediately and began to attend to her 
domestic duties. The tone of the bladder was unimpaired, and she retains 
her urine without any difficulty or uneasiness, feeling in every respect, as 
she expresses herself, as. well as ever. 

Case III. This patient, Mrs. P. M., aged about 20, was confined for the 
first time about two months previous to the time of my seeing her. The 
only account she could give of her case was that her labour had been a 
tedious one, complicated with a prolapse of the funis. She could, how- 
ever, give no information as to whether instrumental means had been 
resorted to in effecting delivery. The main difficulty we had to contend 
against in operating was the extreme nervousness of the patient, the 
operation being much embarrassed thereby. 

The fistule was about half an inch in length, situated an inch below the 
os uteri, in the median line, its shortest diameter being transverse. 

On Tuesday, April 23d last (1861), assisted by Drs. Gregg and Baker, the 
operation was performed in the following manner : Both edges of the fissure 
were seized at the same time and approximated by a pair of strong forceps 
with toothed extremities, and the vaginal septum being well elevated so as 
to bring the parts on the stretch, the entire edge of the fistule was sliced off 
with the curved knife at a single sweep. The angles were then more ac- 
curately and thoroughly cut out with the curved scissors. A soft sponge 
was then introduced into the wound and the patient allowed fifteen min- 
utes' rest. Four sutures of silver wire were then introduced transversely 
and twisted to their positions as in the preceding operations. The ends 
of the wires were confined together to the thigh by a tape, the catheter in- 
troduced, and the same general directions given for the management of the 
case, as before stated. 

The catheter was removed about once in two hours, and the vulva well 
cleansed. The sutures were removed on Thursday, May 2d inst., union 
being complete. The line of cicatrization was pencilled with a stick of 
lunar caustic. The catheter was introduced every two or three hours, but 
on the second day after the removal of the sutures, the patient discon- 
tinued its use, the sphincter vesicas having recovered its tone. Since then 
the patient has resumed her usual duties, and is in every respect well. 

These cases are presented to the profession as an additional tribute to 
the already well-earned reputation of Dr. J. Marion Sims, to whose patient 
investigation and earnest zeal we owe the perfection of an operation, the 
failure to accomplish which with any degree of certainty was for a long 
time one of the opprobria of surgery. Through his skill and ingenuity, 
together with the contemporaneous investigations and experiments of his 
worthy and illustrious compeer Dr. Bozeman, we are now enabled, with 
assurance of success, to promise relief to those afflicted with this most 
serious and distressing lesion. 

It may not be out of place here to bring prominently before the profes- 



1861.] 



Brainard, Spina Bifida, 



05 



sion one or two practical points deduced from the history of the above 
cases. One of these is the non-necessity of observing a rule, so universally 
insisted upon by surgeons in these operations, namely, of restraining the 
action of the bowels during the whole period of confinement, usually nine 
to ten days. In many instances such a course must be attended with great 
inconvenience as well as some degree of danger. In the four cases (the 
other operated for in December, 1859) in which the writer has operated, 
the attempt to constipate the bowels has always been followed with un- 
pleasant consequences. Another fact deduced from the result in the second 
case here reported, which, as far as the writer knows, is the most extensive 
vesico-vaginal fistula yet successfully operated upon, is the complete efficacy 
of the most simple and uncomplicated plan of operation, the use of the 
simple twisted silver (or other metallic) wire suture. It is fair to presume 
that if this operation has succeeded in a case of such extent and with such 
a great loss of substance, it will answer the purpose in any case. 

The object should be to simplify our operative procedures as much as 
possible. Whatever is unnecessary and superfluous only complicates and 
delays. In the hands of such an accomplished and skilful surgeon as Dr. 
Bozeman the button suture doubtless is most successful ; but for the large 
majority of those who may be called upon to treat such cases, the simpler 
the contrivance, if it answers the purpose, the better adapted it is to their 
wants. 

After Dr. Bozeman, the object of some operators, who have turned their 
attention to this branch of surgery, seems to have been more to devise 
something new in the way of apparatus, no matter how complicated it may 
be and difficult of application, than to effect their purpose with the least 
difficulty and the most celerity. We think they are taking a step in the 
wrong direction, burdening the operation with useless incumbrances, and 
thus deterring many from undertaking what otherwise would, in ordinary 
cases, be a comparatively simple matter, by making it appear a very intri- 
cate and complicated one. 

Davenport, May 27, 1861. 



Art. YII. — Spina Bifida, treated by Iodine; Cure by one Injection. By 
Daniel Brainard, M. D., Professor of Surgery in Rush Medical Col- 
lege, etc. 

November *lth, 1860, a girl three years old was brought to me to be 
treated for spina bifida. The child was intelligent, healthy, and well 
formed in every respect excepting the tumour situated over the sacrum. 
This was eight inches in circumference at the base, about two and a half 
inches in height, conical, translucent, elastic, and covered with healthy skin 
excepting a small point at the lower part where it was discoloured like the 
vestige of a nsevus. Below the tumour there was an umbilicated depres- 
sion like a cicatrix adhering to the sacrum. 

Operation. — Nov. 10th, 1860, assisted by Prof. Ephraim, In galls and 
Dr. Edwin Powell, the operation was performed as follows : A small 
sized hydrocele trocar was carried into the tumour at its base on the right 
No. LXXXIIL— July 1861. 5 



66 



Brainard, Spina Bifida. 



[July 



side, and six ounces of fluid drawn off; while this was flowing, pressure was 
made by an assistant, and as the sac was emptied, the pulp of the thumb 
was pressed upon and partly into the opening in the spine which it exactly 
filled, so as to close it as perfectly as possible. Half an ounce of a solu- 
tion (five grains iodine, fifteen grains iodide potass to the ounce distilled 
water) at the temperature of the body, was then injected through the 
canula and after a few seconds allowed to flow out ; distilled water at the 
temperature of the body was thrown in to wash out the iodine, and two 
ounces of the fluid first drawn from the sac and kept at the same tempera- 
ture, were re-injected and the canula withdrawn. From movements of the 
child, some bubbles of air passed into the sac, and as these could not rea- 
dily be brought out they were left. 

During the operation the child was kept under the influence of chloro- 
form, of which it required a very unusual quantity, and, when this was 
finished, it remained fifteen minutes in a quiet sleep. 

The puncture was dressed with a strip of isinglass plaster and a com- 
press supported by a band around the pelvis placed over it. 

On awakening, the child made efforts to vomit and seemed to be severely 
nauseated for half an hour, when it fell into' a light sleep. During the 
afternoon it vomited occasionally, refused food, asked for cold water, and 
urinated often. 

11th. Has been restless during the night, probably from being kept lying 
on the face ; pulse and heat of skin natural, puncture at eleven o'clock ; twenty- 
four hours after the operation, found to be leaking ; tumour tense ; applied 
more perfect compression over it. DuriDg the day child drank freely of 
toast, water, and in the afternoon fell into a free warm perspiration, which 
lasted two hours. 

12//?. Has slept well, asked for toasted bread twice, and ate it; seems 
perfectly well. 

13//?. Tumour tense, redness around the puncture ; applied cloths dipped 
in warm water. 

15th. Puncture leaking ; passed a fine needle through the edges, tied a 
fine thread around it, in form of twisted suture. 

11th. Tumour tense; tapped it on the left side near the base on sound 
skin with an exploring trocar, and drew off six ounces of slightly turbid 
fluid. Continued warm water applications. 

19th. First puncture leaks slightly ; needle withdrawn and compress 
supported by a truss placed over it. 

20//?. First puncture closed ; child in its usual health, tumour flaccid, 
walls slightly firmer than before the operation. Translucency quite gone. 
Applied an India-rubber band around the pelvis so as to compress the sac. 

25th. Tumour much diminished ; walls firmer. Removed the band and 
substituted an umbilical truss, the pad of which was placed over the sac. 

30//?. Child in good health ; tumour diminishing. 

Dec. 3. Tumour but imperfectly fluctuating and evidently filled with 
semi-solid contents. 

From this time to December 31st the truss was kept applied with com- 
presses of fine linen within the centre, so as to press the skin into the 
opening in the spine. It was taken off and replaced daily, so as to avoid 
excoriation. The child suffered no pain, was in perfect health, and played 
about as before the operation. 

31s/. She skin at the centre of the tumour is adherent to the opening in 
the spine, which is felt to be closed. A little fulness around the base at 



1861.] 



Brainard, Spina Bifida. 



GT 



the upper part alone marks the vestige of the tumour. I advised the con- 
tinued wearing of the truss unless it should excoriate, and the parents left 
for home. 

Feb. 10. Child has remained well; no tendency to return in the tumour. 
Truss has been left off for several weeks at a time when the pressure pro- 
duced restlessness. 

The fluid first drawn from this tumour was perfectly limpid, had the 
peculiar odour of the cerebro-spinal fluid, was very slightly albuminous. 

With the microscope, only a few epithelial scales, and a trace of coagu- 
lated fibrin, could be detected. That drawn on the seventh day was turbid, 
and on cooling deposited a sediment composed of coagulated albumen and 
fibrin, with what appeared to me to be pus-globules here and there. These, 
if I was not mistaken in their character, must have come from the internal 
orifice of the puncture, which was still leaking. 

Bemarks. — This is the seventh case of spina bifida which I have treated 
by iodine injections. In no case have I seen it produce dangerous symp- 
toms. It is the third unaccompanied by hydrocephalus ; all these three 
have been perfectly and permanently cured — one with thirteen injections, 
one with two, and the last with one. In the last two, means were taken 
to prevent the passage of the solution into the spinal canal. In one, the 
tumour being pediculated, this was easily done ; in the other, the means 
above described were resorted to with satisfactory results. When this can 
be effected, the solution may be used strong, and washed out so as to render 
one or two operations sufficient. The object of reinjecting some of the 
fluid in the case above reported, was to enable a hand around the pelvis to 
effect some pressure on the cord. 

The operation is so delicate that it is not easy in any case to fulfil all the 
requisite conditions. Thus, in the above case, the walls were so thin at the 
point of puncture, that it did not close for ten days, constituting a source 
of danger. Some bubbles of air also passed in, to which too much conse- 
quence need not be attached, as no harm resulted ; but it would be prefera- 
ble to avoid such an occurrence. 

Applications of collodion for the cure of spina bifida have been recently 
suggested. When the walls are thick and firm this may be safe, and will 
be as serviceable as other forms of compression. When the covering is 
thin, it is dangerous. Dr. James Gow reported, in the Chicago Medical 
Journal for November, 1860, a case where it caused ulceration and rupture. 
Prof. Gross reports, in the North American Medico- Chirurgical Beview 
for November, 1860, a case of this malformation, treated by injection of 
iodine. "The tumour was thoroughly painted over with collodion." The 
tumour opened (not at the point of puncture) on the second day, and on 
the sixth it "burst completely. 7 ' Although the covering is stated to have 
been "on the point of bursting" before the operation, it seems probable 
that the collodion hastened if it did not cause the rupture. 

In another case by Prof. Gross (ib.), where about ten injections were 
used in eight weeks, the collodion was kept applied, and the tumour burst, 



6S 



Brainard, Spina Bifida. 



causing death. Concerning this ease, there are two points deserving no- 
tice : — 

1. As there is no reason to suppose that the rupture was caused by the 
injections, it must be attributed to the collodion. 

2. As the tumour was found on dissection to be " about one-third oblite- 
rated by coagulable lymph," the inquiry naturally suggests itself, whether 
one or two injections would not have been sufficient. A certain thickening 
of the walls has indicated to me that further injections were unnecessary, 
and the loss of translucency, or the turbid appearance of the fluid with- 
drawn are indications of a change in the structure and action of the lining 
membrane, sufficient, with judicious pressure, to effect a cure. 

As these cases of Prof. Gross, taken without detail, are calculated to 
discourage the trial, it may be well to note that, although about ten injec- 
tions were made so as to pass in some degree into the spinal canal, " the 
child early suffered from the convulsions after the operations, and they 
always readily yielded to a dose of castor oil." 

I regard both the cases of Prof. Gross as tending to show the safety 
and efficiency of this method of treatment, as in both plastic lymph was 
deposited within the sac without any dangerous symptoms attributed to 
the operation having occurred. 

The manner in which collodion acts in producing ulceration is threefold : 
1. By vesication ; 2. By expelling the blood from the thin walls ; 3. By 
increasing the tension of the walls of the sac, which it does by diminishing 
its size. 



1861.] 



69 



TRANSACTIONS OF SOCIETIES. 



Art. YIIX. — Summary of the Transactions of the College of Physicians 

of Philadelphia. 

1861. Feb. 6. Report on Meteorology and Epidemics for 1860. — 
Dr. W. Jewell read the following report : — 

In offering my report for 1860, I must again acknowledge my indebted- 
ness to James A. Kirkpatrick, Esq., Prof, of Civil Engineering in the 
Philada. High School, for an abstract of the tables of his meteorological 
observations during the year. (pp. 82-83.) The accuracy of these tables 
is undoubted, while their usefulness for present and future reference will 
be admitted. 

The following summary of these observations is from his own pen. 

The mean temperature of the year (1860) was less than four-tenths of 
a degree below that of the year 1859, and nearly two-tenths of a degree 
below the average for the last nine years. 

The maximum temperature (95J°) occurred on the 20th of July. The 
minimum temperature, one degree above zero, was on the 2d of February. 

The warmest day of the year was the 20th of July, when the mean tem- 
perature was 8T.t°. The coldest day was the 2d of February, the mean 
for that day being 9.2 degrees. 

Of the seasons, the spring was one degree warmer, and the summer one 
degree colder than the average for nine years, while the winter and autumn 
were very close to the average. 

Of the months, the greatest variation from the average was in Decem- 
ber, which was nearly 3° colder than usual, and was the coldest December 
since 1856. 

The maximum pressure of the atmosphere (29.418 inches), occurred on 
the 14th of December; and the minimum pressure (29.099), on the 18th 
of February. The average pressure was very nearly the same as that for 
1859. It may be interesting to notice that the average pressure, as indi- 
cated by the mean of the three observations, is very nearly the same as the 
mean of the observations at 9 P. M., the difference for the whole ten years 
being only .002 of an inch. 

It is becoming also to inform the college that, in consequence of the 
inauguration of the new law for the registration of births, marriages, and 
deaths, which went into operation, under the supervision of the Board of 
Health, on the 1st of July, 1860, I have rearranged the tables, that they 
might conform to those published by that Board, and have added tables of 
the births and marriages registered since the law was enforced. 

I have also changed the order of grouping the diseases, which order has 
been faithfully preserved since 1850. This change occurs at a suitable 
time, as the tables already published by the college embrace a statistical 
decade from 1850 to 1859, and is well adapted for calculations as to the 
vital statistics of our city. 



10 Transactions of the [July 

No apology need be offered for making this alteration. As a member of 
the committee " on a uniform plan of registration reports of births, mar- 
riages, and deaths," appointed by the American Medical Association, and 
whose report was adopted by the Association at its meeting in Louisville, 
Ky., May, 1859, and subscribing cordially to the suggestions therein made, 
I could do no less, when an opportunity offered, than to follow out the recom- 
mendation of the committee for the forms of tables — both as to the classi- 
fication and nomenclature of the causes of death — which, with but few 
alterations, are the same as were adopted by the Association in 1847. 
This favourable opportunity has occurred, and I have embraced it, in 
framing this report. Another feature herein embodied, and one that modi- 
fies the report in several respects, is the reference to the statistics of our 
total population, as well as of the population of the several wards. This 
modification has been effected through the operation of the eighth U. S. 
Census, which was taken during the month of June, 1860. 

From the figures, as given by the marshal of this district, I find that he 
makes our population 568,034, an increase over the population for the 
census of 1850 of 159,272, or 39 per cent. Should this statement be cor- 
rect, it gives us an average growth of about 3 per cent, per annum. But 
the question arises, have authentic returns been received ? "When we take 
into consideration, the usual growth of large cities — which will exceed 5 
per cent. — the length of time occupied in obtaining the returns — a month — 
the season of the year — June — when a large portion of our population had 
left the city for the summer, and the number of houses shut up, where no 
answers could be obtained, the natural inference will be, that justice has 
not been done to the vital statistics of Philadelphia. This opinion is by 
no means peculiar to myself. There are others who have investigated the 
subject, and are satisfied that the total of population as given in the mar- 
shal's returns, is below the actual number, and at variance with facts. But 
such is the census return, and it goes abroad as correct. During the present 
decade, therefore, we shall lose the advantage we would otherwise gain 
from a true record of the number of our inhabitants ; unless Councils should 
determine to have a census taken, in order to place the city, in point of 
population, where she rightfully belongs, as has been properly suggested 
by the mayor in his last message to that body. 

The introduction of the tables of births and marriages, for the last six 
months of 1860 — if not of any practical application at the present time, 
seems to be proper, in order to preserve an entire uniformity with our new 
system of registration, and thus establish a plan after which our vital sta- 
tistics and our sanitary inquiries may be framed in the future. 

From the annual report of the Board of Health I learn that, thus far 
the law for the registration of births, marriages, and deaths which this col 
lege, in connection with the Philadelphia County Medical Society, was 
instrumental in having enacted, "is popular, and its present success not 
only affords an evidence of the appreciation in which it is held by the 
most of those interested, but gives encouragement for its future progress 
and permanency." 

" The registration of the names of all persons who are required to make 
returns under this law, has been, with a few exceptions, both cheerfully 
and faithfully complied with by the parties themselves. The necessary 
register has been alphabetically arranged under three distinct heads, and 
contains at this time the autographs of 1302 clergymen, physicians, &c, 
with their respective residences in our city, as follows : — 



1861.] College of Physicians of Philadelphia. Tl 

Clergymen 370 

Clerks of the records of religious societies 4 

Physicians ........... 701 

Practitioners (female) of midwifery . . . . . . 51 

Mayor 1 

Aldermen ........... 36 

Undertakers . . . . . . . . . . . 79 

Superintendents of burial grounds ...... 60 



1302 

" Since the law went into effect, up to the 31st of December, 1860, a 
period of six months, there have been returned and registered 8434 births, 
2310 marriages, and 6342 deaths. 

" It would be unreasonable to suppose that the statistical contributions, 
as detailed in these registers, could at this incipient stage of the record be 
made available, or answer any valuable purpose in reference to the vital 
statistics of our city. All that is contemplated in this first report, is to 
furnish an abstract of the returns in tabular form, which will serve as a 
basis of reliable data for the preparation of future reports. It is only by 
the accumulation of facts connected with vital and mortuary statistics, 
during a succession of years, carefully and intelligently collated, and accu- 
rately aggregated and compared, that the laws governing human existence 
can be determined. 

" Each new annual report will be entitled to additional consideration 
from its increased value, arising from the useful information it will furnish 
to those who shall hereafter engage in the investigation of the science of 
vital statistics. We trust, therefore, that the inauguration of this new and 
important system is the beginning of a reform in the science of life in our 
city, and that this limited contribution may be followed annually hereafter 
by more extended, more valuable, and more interesting reports." 

I have also availed myself of several of the tables, for this report, as 
compiled by the registration clerks of the health office, because they were 
prepared according to the instructions of your reporter, and are in con- 
formity with his own views of tabulating and collating the records of 
births, marriages, and deaths. 

Births. — The number of births returned and registered for the six 
months of the year, under the new law, will be found in Table I. They 
amount to 8,434. Of these, 4,426 were males and 4,008 females. An 
excess of male births equal to 10.40 per cent. 

In the same table will be found the births that occurred in each of the 
six months; those in each ward of the city ; the population of each ward 
according to the census returns, together with the percentage of births to 
population in each ward. 

From this we learn that the Nineteenth Ward furnished the highest 
number of births, viz., 623, and the Eighth Ward the lowest number, viz., 
184. 

August seems to have been the most prolific month in births, giving 
1,575, while December gave but 1,247. 

According to the population of the wards, the highest percentage of 
births must be awarded to the Seventeenth, viz., 456, or 1.95 per cent., and 
the lowest to the Eighth, viz., 184, or 0.66 percent., while the ratio of 
births to population in each ward is in favour of the Seventeenth, which 
yielded 1 in every 51. 

The registration of births of coloured children, amounting to 148 — 82 



72 Transactions of the [July 

males and 66 females — can hardly be relied upon for its correctness, as I 
have reason to believe that the colour in every instance has not been desig- 
nated. 

Fifty -seven cases of twin births were registered, and there was one instance 
of triplets. 

The month of August yielded 15 cases of twin births, December 11, July 
10, November 9, September 7, and October 5. 

As an evidence of the estimation in which the registration law is held 
by those who are required to make returns of births, there were only 155, 
or less than 2 per cent, returned without the location being designated. 

If the returns of births made for the last six months are to be considered 
as the half of those that' have occurred for the year, they would give a total 
of 16,868, which is equivalent to 1 in every 35 of our population, allowing 
that our population is equal to 600,000 instead of 568,034, as given by 
the census. These returns are a more favourable indication of the general 
hygienic state of the city than has ever before been shown by our birth 
statistics. 

The stillborn children for the six months numbered 347 — 208 males and 
139 females — an excess of 69 male births, equal to 50 percent. The still- 
born are included in the general table of births, according to the recom- 
mendation of the American Medical Association. They were in the 
proportion to the living births as 1 in every 24, or 4 per cent. 

Marriages. — Since July 1st, the number of marriages registered under 
the new law amounts to 2,310. See Table II. 1 

Of the number registered, 2,371 of the parties were Americans by birth, 
and 1,961 were born in other countries. The birthplaces of 288 were not 
given. 

Of the married couples, 1,138 of the grooms, or 49 per cent., were born 
in the United States; 1,025, or 44 per cent., were of foreign birth, and of 
147, or 6 per cent., the birthplaces were omitted. 

Of the brides, 1,233, or 53 per cent., were native born; 936, or 40 per 
cent., were of foreign birth, and 141, or 6 per cent., were registered as 
unknown. 

The instances in which American men married American women were 
999, or 43 per cent. ; while those cases where both parties were of foreign 
birth amounted to 801, or 34 per cent, of the whole. 

Only 125, or 5 per cent, of American men married women of foreign 
birth, while 220, or 9 percent, of American women were united to foreigners. 

Table III. gives the ages of the parties married. Of the grooms, only 
10 were under 20 years of age; 834, or 36 per cent., were between 20 and 
25 years; 635, or 27.35 per cent., between 25 and 30 years; 433, or 18 
per cent., between 30 and 40 years; and beyond that period of life there 
were 154, while of 244 grooms the age has been omitted. 

Of the brides, 464, or 20 per cent, were under 20 years of age; 948, or 
41 per cent., between 20 and 25 years; 369, or 16 per cent., between 25 
and 30 years; 217 between 30 and 40 years; beyond that age there were 
only 60 registered according to age, while in 252 of the marriages the 
ages of the brides were not given. 

1 This, however, cannot be considered a correct estimate of the marriages in our 
city. That it falls short of the true number I have not a doubt; at the same time 
it must be received as a fair beginning for the inauguration of a law which, judging 
from the returns, has but few friends among the clergy. 



1861.] College op Physicians op Philadelphia. 73 

The greatest inequality of ages was presented in the marriage of a groom 
between 60 and 70 to a bride between 20 and 25 years of age. 

There were 8 grooms registered under 20 years of age. One groom was 
18 and his bride It years of age. 

The popular age for marriage, according to this table, is between 20 and 
25 years. The second favourite age, with females, is under 20 ; but with 
males, between 25 and 30 years. 

Mortality of Philadelphia. — Herewith will be found a general sum- 
mary of deaths for the year. It is so divided or classified as to show at a 
glance the white and coloured, the male and female, the adults and minors, 
those deaths from actual disease, and those from accidental or other exter- 
nal causes. 



General Summary of Deaths. 

Total number of deaths reported for 1860 . . . . . 11,568 

White 10,949 

Coloured 619 



Total . 11,568 

Males 6,109 

Females . . 5,459 



Total 11,568 

Male minors or children ..... 3,594 
Female " " 3,125 



Total minors 6,719 

Male adults 2,515 

Female adults . 2,334 



Total adults 4,849 

Deaths from registered diseases .... 10,055 

Deaths from stillborn ...... 719 

Deaths from old age . . ... . . 213 

Deaths from unknown external and accidental causes 581 



Annual total of deaths from all causes ... . . . . 11,568 



According to the above summary, the deaths for the year, from Dec. 31, 
1859, to Dec. 29, 1860, amount to 11,568. 

This mortality shows an increase of 1,826, or 18.74 per cent, over that 
for 1859. 

This augmentation in our mortality may be ascribed principally to the 
increased force and diffusion of certain diseases ; while the improved system 
of collecting the deaths under the registration law, which has been in ope- 
ration since the first of July, has no doubt furnished us with more correct 
returns. 

It is well understood that during 1859 our city was favoured with a 
remarkable degree of health. The deaths were 9 per cent, below those of 
1858, and 12.19 percent, below the average of deaths for the previous four 
years. 

Nor did it create any surprise that the correctness of the returns for that 
year as presented in my report to the College, should be questioned by 
statisticians abroad. And notwithstanding there may be causes that have 
been developed since the new law of registration went into operation to 
account in some measure for the limited returns of deaths in 1859, still, 
when I consider that the mortality was 12 per cent, below that of the 



n 



Transactions of the 



[July 



average of deaths for the preceding four years, which deaths were returned 
under the same law, and when I know, from a comparison of the records 
for 1859 and 1860 that there has been an increased force and diffusion of 
certain diseases during the latter year, I am not prepared to ascribe either 
the limited number of deaths in 1859 altogether to defective returns, or the 
augmentation of deaths in 1860 altogether to the improved system under 
the new law. 

An examination of the returns for the first six months of 1860, which 
were made under the old law, shows an increase of 7.55 per cent, over 
those for the same period in 1859; while the deaths in this latter year were 
9 per cent, less than those in 1858; and when I discover that the deaths 
from diphtheria and scarlet fever in the last six months of 1860 have in- 
creased 343 per cent, over those for the last six months of 1859, I cannot 
be forced to the conclusion that the augmentation of deaths in 1860 is 
attributable to the defective returns under the old law. 

If I have been led into any error in my calculations for 1859, it must be 
ascribed to the circumstance of overrating the population, an error into 
which statisticians in large cities have been sometimes led. 

Of the total of deaths 6,109 were males and 5,459 were females; an 
excess of male deaths equivalent to 12 per cent. 

The mortality among minors, or those under twenty, was 6,719, while 
that of adults was only 4,849; an excess of deaths equal to 38.35 per cent, 
of the former over the latter. 

The mortality of children under five years of age as compared with the 
total mortality was 5,704, or 49.30 per cent. This heavy and frightful 
mortality during infancy is no more peculiar to our own than to other large 
cities. Yiewed in a sanitary aspect, there is much in this pressure on infant 
life worthy our consideration. 

It is scarcely a matter to be questioned, because acknowledged by all who 
have investigated the subject, that one of the principal causes for this enor- 
mous death-rate of our infant population is the unhealthy condition of the 
atmosphere we breathe. Nor is it less obvious that the catalogue of dis- 
eases to which the deaths among children are assigned, embraces chiefly 
that class called preventable, or those depending upon local and removable 
causes. 

In Table IY. will be found the record of deaths from Dec. 31, 1859, to 
June 30, 1860. This period terminated the existence of the system of 
collecting and recording the deaths and births under the old health law of 
1818. It tabulates the number and causes of death, with the sexes, and 
periods of life when they occurred, for the first six months of the year. 

Table Y. gives the deaths, under the new law, for the past six months, 
with the sexes, the adults and minors, as also the several periods of life 
when the deaths occurred, and the total number deceased for each term 
designated. 

Table YI. furnishes the wards, with the number of deaths in each ward 
from the several diseases named, together with the deaths from the Alms- 
house, the country, and those among the people of colour, with the nativity 
of the deceased. It will be observed that 4,888, or 77 per cent., of those 
who died were born in the United States, those of foreign birth amounted 
to 1,096, or 17.28 per cent., and of unknown nativity there were registered 
358, or 5 per cent. This table also gives the population of each ward, 



1861.] College of Physicians of Philadelphia. 75 

together with the ratio of deaths to population, and percentage of deaths 
in each to the total mortality for six months. 

The heaviest mortality according to population was in the Fourth Ward, 
equal to 1 in every 61 ; the next highest was in the Secoud Ward, 1 in 69. 
In the Seventeenth Ward the rate of deaths stood 1 in 16 ; in the First 
Ward 1 in 83; in the Third Ward 1 in 84; and in the Seventh and Nine- 
teenth Wards 1 in 87. 

In most of these wards, where the mortality has been the heaviest, an 
explanation for the high death-rate will be found in the character of a part 
of the population, the manner in which they live in crowded apartments in 
narrow streets, blind courts and alleys, amid dampness and filth, without 
sufficient light and ventilation, badly fed and clothed, and subjected to 
other defective sanitary arrangements. Whereas, in other wards, where 
the population was proportionably large, but less crowded, and enjoying 
more of the comforts and conveniences of life, with an adequate supply 
of light, and sufficient ventilation, the death-rate was comparatively low. 
For instance, in the Thirteenth Ward, where the population rated 20,132, 
there were only 123 deaths, in the ratio of 1 death to every 163, or 2 per 
cent, of deaths to the total mortality ; while in the Fourth Ward, already 
alluded to, where the population was but 23,633, there were 385 deaths, or 
1 to every 61 of its inhabitants, and equal to 6 per cent, of the total mor- 
tality ! Such is the contrast, in the mortality of our city for the last six 
months of 1860, between a favourable and unfavourable sanitary district. 

Similar comparisons may be instituted between the healthy and unhealthy 
states of other wards by a reference to the table. 

Table YIL, Class L Zymotic or Epidemic Diseases. — Adopting the 
classification of diseases as recommended by the American Medical Associ- 
ation, I now refer to those deaths which come under that division called 
Zymotic, and which have an epidemic, endemic, or contagious character. 

By a careful investigation of the death-roll, it will be found that this 
class of diseases, which depend upon the altered condition of the atmo- 
sphere, and upon local causes, either for their existence or their fatality, 
are among the most active in swelling our bills of mortality. The total 
number of deaths from this class during the year amount to 2,275, or 
22.62 per cent, of the deaths registered from diseases, or 1 in every 5 of 
the total mortality. Class I. holds, therefore, an important place in the 
mortality record of our city, furnishing a heavy percentage of the deaths; 
while at the same time it is capable of demonstration that this form of 
disease is fostered by predisposing causes which in a great measure are 
capable of being removed by sanitary police regulations. 

In this class will be found those diseases which press heavily on infant 
life — and they are mostly the result of causes that are local and removable, 
of an endemic and avoidable origin. The extent of mortality among minors, 
in this class, over adults, is equal to 362.4 per cent., or more than 4 of the 
former to 1 of the latter. An improvement in the sanitary condition of 
our city will diminish the annual death-rate from zymotic diseases. In 
evidence of the correctness of this opinion, an examination of the record 
will show that the highest mortality from such diseases has been in our 
densely populated wards, and those which are not favoured with advantages 
that have a direct tendency to mitigate the destructive influence of the 
cause or causes of epidemic and endemic diseases. 

Cholera Infantum, a disease peculiar to cities, and confined to the sum- 



76 



Transactions or the 



[July 



mer months, destroyed 514 children. The heaviest mortality since the 
operation of the registration law, July 1st, was in the Nineteenth, Seventh, 
Fourth, Third, Twentieth, and Seventeenth Wards, in the order in which 
they are named. It is well known that these wards are overcrowded and 
contain localities which are badly ventilated, maintain a squalid population, 
and are peculiarly adapted to invite and determine the onset of disease. 
Nevertheless, cholera infantum is on the decline in our city ; and, while I 
admit that the deaths from it have increased 26 per cent, over those for 
1859, still if the average for the last four years be taken, it will furnish 
the evidence that I am correct. Nor can this mitigation of a fatal disease 
among children be attributed so much to an improved condition of the 
localities where it has been too often a familiar visitant, as to those advan- 
tages alluded to in my last year's report, which are afforded the population 
of our crowded courts and narrow alleys for securing a change of air by 
means of the numerous city railroad conveyances that safely glide in every 
direction through our streets, at all hours of the day. 

In this connection I embrace the opportunity of expressing, my thanks, 
as a sanitarian, to our city authorities for the liberal measures they have 
devised to improve the several grounds at Fairmount, more particularly 
those of Lemon Hill and Sedgely Park. As a public provision for the 
security of the health, as well as for the enjoyment of the masses, these 
pleasure grounds cannot be too highly prized. With the facilities for 
reaching them from all points of the city, that portion of our population 
whose circumstances restrict them to a residence in crowded and pent-up 
localities, where the air does not circulate in its purity, have herewith 
afforded them a healthful resort. Here wornout wives and enfeebled chil- 
dren can enjoy a pure atmosphere during summer's heat, and pass away 
hours watching the romantic Schuylkill, as its silvery stream winds along 
the western slope of the park, or strolling through shaded groves and 
walks adorned with luxuriant foliage. The establishment of these parks 
for the people is a great sanitary movement on the part of the authorities, 
but it is not sufficiently appreciated by the community. What by many is 
considered to be a lavish waste of public funds in appropriations for the 
embellishment of these great lungs to the city, is, if rightly viewed, a public 
saving — a gigantic sanitary protection against the inroads of pauperism — 
a check upon sickness among the working classes ; it becomes indirectly a 
benevolent provision for the security of the public health, and thus adds 
to the vital prosperity of our population. 

In my report for 1859, I intimated the existence of indications that 
before a great while we might have to combat with diphtheria — a prognosti- 
cation that has to a large extent been realized during the year 1860, the 
deaths having amounted to 307. This mortality, as shown by the record, 
has observed a gradual increase for each successive quarter, as follows : 1st 
quarter, the deaths were 36; the 2d, 57 ; the 3d, 75, and the 4th, 139. 
During the last six months of the year, the heaviest mortality occurred in 
the first four wards of the city, amounting to 49. The 18th, 19th, and 
20th wards furnished 43 deaths, the 14th and 15th wards added 28, while 
the 7th ward gave 11 deaths. These wards are densely populated, and 
in all of them may be found locations peculiarly adapted to the propaga- 
tion of epidemic diseases, from their low hygienic condition. At the same 
time, it is but proper to state that cases of diphtheria, and many of them 
resulting in death, have been quite prevalent in the more salubrious, ele- 



1861.] College of Physicians of Philadelphia. 11 

vated, and well ventilated sections of the 14th and 15th wards, where it 
would be less likely to spread through infection or contagion. 

Of the deaths recorded for the whole year from diphtheria, 142 were 
males, and 165 females, an excess of 16.33 per cent, of females. Among 
adults, there were only 12 deaths, the remainder, 295, were under twenty ; 
of these, 31 were under 1 year; 56 between 1 and 2 years; 116 between 
2 and 5 years ; 68 between 5 and 10 years, and 18 between 10 and 20 
years. The heaviest mortality was in children between 2 and 5 years of 
age, equal to 164.6 per cent, of the deaths from diphtheria. 

Both the character and treatment of diphtheria have been subjected to 
a wide difference of opinion in medical circles during the past few years. 
The mauner of its propagation — whether by direct contagion, or infection 
through an aerial poison ; whether it can be conveyed by the clothes of an 
individual visiting a diphtheritic patient ; whether it is epidemic, endemic, 
or sporadic ; whether it is a new or old disease ; whether it is scarlet fever 
or croup, or whether a disease of a specific origin, or of the blood, or one of 
local inflammation — has been frequently discussed. Some view it as scarlet 
fever, while others look upon it as croup. 

That it bears a close resemblance to both of these diseases, cannot be 
denied ; but I am far from believing that diphtheria, as it appeared in our 
city during 1860, is identical with either the one or the other. When I 
have witnessed fatal cases of the disease without the croupal cough, or 
laryngeal inflammation ; when I have seen a child die of diphtheria that, 
one year previously, had scarlet fever in its most malignant form ; and when 
I have seen both scarlet fever and diphtheria side by side in two children of 
the same family, presenting no identity, except in their fatal termination in 
a few days, exhibiting in the one case the laryngeal diphtherite, and in the 
other the true characteristics of congested scarlet fever, of a most malignant 
type, I am sure not to err, if I decide that they are not the same disease. 

I am aware of the close resemblance between diphtheria and scarlet fever, 
and I am sensible, also, that in expressing an opinion as to the specific 
nature of the former to that of the latter, I am running a tilt against the 
judgment of high authority. That the close analogy of the two diseases, 
and their occasional complications, may lead to error in diagnosis, I can 
readily admit, and believe that one has often been treated for the other ; 
and where the two diseases prevail simultaneously — as they have done 
during the year 1860 — much confusion may arise, in designating their true 
character, especially where many of the symptoms differ but slightly. 
Nevertheless, there is a distinct line of demarcation by which the identity 
of diphtheria can be recognized. 

I have at the present time a grave case of diphtheria under treatment. 
The fauces, the pituitary membrane, the pharynx, and oesophagus, were all 
affected with inflammation, as far as could be seen with the eye, followed 
by an exudation of a grayish-white lymph, accompanied with epistaxis, 
and an asthenic condition of the system. It is now in the third week, 
and although the patient is slowly recovering, there is extreme prostration 
of the vital powers, amounting almost to paralysis, particularly of the 
organs of deglutition, which, by some authors, is looked upon as a pa- 
thognomonic symptom of diphtheria ; yet in this family, where there are 
seven children, only two of whom have had scarlatina, not a case, up to 
this date, has occurred of either disease, although the surrounding circum- 
stances would lead to the inference that if it were scarlatina, or even a 
contagious disease, one or more of the family would have been attacked. 



78 



Transactions oe the 



[July 



I have no belief, therefore, in its contagious character. As an epidemic, 
the disease may be communicated through an atmospherical poison. Nor 
am I willing to convey the idea, that in my practice, I should act as if it 
were contagious. Passing through numerous cases of the disease during 
the year, I have not observed a single instance wherein a materies morbi 
was developed, that reproduced itself. 

If diphtheria does bear an analogy to croup in the fact of an adventi- 
tious membranous deposit upon a mucous surface, it is well authenticated 
that this formation commences in the fauces, and may extend to the larynx, 
while that of croup invariably shows itself, and is confined to the larynx 
and trachea. Diphtheritic croupal symptoms are secondary, or accidental, 
while, according to Dr. -Pepper, laryngeal or true croup is a primary affec- 
tion. I have no question as to the distinct character of the two diseases. 

The treatment of diphtheria has been the subject of much diversity of 
opinion. It is, however, almost unanimously conceded that both a local 
stimulative and a sustaining treatment is required from the very commence- 
ment of the attack, especially in those forms of the disease that have ap- 
peared in our city, where an asthenic condition was a marked characteristic. 

Scarlet fever has been very prevalent during the year. The deaths 
amount to 591 ; this is an increase over those for 1859 of 359, or 154 per 
cent, and furnishes a considerable item for the increase of the year's mor- 
tality, especially during the last six months, over that of 1859. Since the 
1st of July, the first four wards, the 7th and 19th, have furnished 55 per 
cent, of the deaths for the six months. The character of the population, 
in many parts of these wards, their crowded and defective sanitary condi- 
tion, to which I have already alluded, will explain the wide-spread preva- 
lence of the disease, and its fatality in those sections of the city. 

Smallpox has been on the increase during the year ; 57 deaths have been 
recorded. Of these, 43 were in the last quarter. Nearly all of them, that 
is, 50 to 7, were in children. 15 of these deaths occurred in the 17th 
ward ; 5 in the 1st, and 6 in the 4th ward ; the remainder were scattered 
over nine of the remaining wards. The disease has been quite prevalent 
in the 17th ward, where it first made its appearance. 

It is a fortunate circumstance that the new ordinance for public vacci- 
nation has been in operation during the last six months, in which period 
3032 children have been reported as successfully vaccinated. Hundreds of 
these children would otherwise have met with an untimely death, especially 
in the 17th ward, where 558 were vaccinated. Nor is it presumptuous to 
say thatj to the neglect of the proper administration of this prophylactic, 
both on the part of the public authorities for a number of years, and of 
those parents who refuse to have their children vaccinated, must be attri- 
buted the amount of smallpox prevailing in our city at this time. On this 
subject, I cannot do better than to repeat the views expressed by me in 
another place, on the gratifying improvement in the system of public vac- 
cination. Believing it to be only one step forward, I have remarked — and 
every intelligent medical man will surely indorse the sentiment — that "a 
still higher standard, embracing more adequate provision, is demanded, 
before a perfect report of the successful state of vaccination in our city can 
be exhibited. The ordinance now in force is purely benevolent in character, 
and strictly voluntary in its import. It offers gratuitous vaccination to 
every individual, and provides an easy method to secure the gift. Unfor- 
tunately, however, what with apathy and indifference with some, and pre- 
judice on the part of others, this inestimable sanitary blessing is too often 



1861.] College of Physicians of Philadelphia. 79 

refused, to render it an entire security against the introduction of small- 
pox. 

" What we require, is a compulsory system, under legal enactment, im- 
posing a penalty for disobedience to its provisions, requiring every child 
born, or brought into the city, to be vaccinated, and making it an impera- 
tive obligation that satisfactory evidence of vaccination shall be given as a 
prerequisite for admission of children into our public schools. This law, 
in order to operate effectually, should apply to our entire State." 

The deaths from enteric or typhoid fever were 213, and they have 
fallen off 20 per cent, from those of 1859. The miasmatic fevers recorded 
are so limited in number as not to require any special notice, further than 
the remark that, for the last few years typhoid fever, from its prevalence, 
seems to have become the ordinary endemic of the city instead of mias- 
matic fevers. ■ 

Measles, among the exanthemata, has fallen off 73 per cent., only 15 
deaths having been recorded. 

Dysentery furnishes 178 deaths; it has increased 38 per cent, over those 
for 1859. 

Four deaths from cholera, and 24 from cholera morbus are recorded. 
The four deaths from cholera were in the third quarter ; three of them 
occurred in the Seventh, Tenth, and Nineteenth Wards. 

A single death is registered Typhus Icterodes or Yellow Fever. This 
case was in the month of September, in the person of a German labourer, 
about 40 years of age, residing in a German boarding-house on Front near 
Coates Street, He was employed in unlading rafts at Green Street wharf, 
and had not been absent from his work the whole season. Throughout 
the entire week he laboured in the docks during all stages of the tides, 
and the hottest hours of the day, subjected to wet feet, and exposed at 
low tide to the offensive and noxious exhalations emanating from the mud 
and filth of these unhealthy localities. The case occurred under circum- 
stances that forbid the possibility of referring it to a foreign origin. It 
was a sporadic instance, from a local cause, terminating fatally on the 8th 
day from the attack. No other case occurred in the neighbourhood. Of 
its being genuine yellow fever not a doubt was expressed by any one who 
saw it, and the post-mortem revelations confirmed the diagnosis. 

Table YII., Class 2. General or Uncertain Seat. — The deaths from 
diseases of this class, or those whose seat is of variable, uncertain, or doubt- 
ful location, amount to 1656. Debility, which is only a condition of the 
system the result of disease, having no definite meaning, and should seldom 
if ever be applied as the cause of death, furnished 538 of the number ; 
while marasmus, otherwise atrophy, and having a very general meaning in 
death certificates, gave 478 — making up 1016, or 61.3 per cent, of the 
deaths in this class. 

Table YII, Class 3. Diseases of the Nervous System. — They num- 
ber 1,966; of these, 980 were in the first six months, under the old law, 
and 986 in the last six months, under the new law. They constitute 19.5 
per cent, of all the deaths from registered diseases. 

1,240, or 63 per cent, of the deaths in this class, were in children under 
10 years of age; of these, 513 are recorded under convulsions, and 266 from 
inflammation of the brain. 

Apoplexy and palsy, two diseases which almost invariably are related as 
cause and effect, produced 273 deaths; the former 143 and the latter 130. 



80 



Transactions of the 



[July 



The increase over those for 1859 is 41 per cent. 157 of the deaths were 
recorded as disease of the brain ; but what particular disease, whether epi- 
lepsy, dropsy, inflammation, or mania, is not given. 

22 deaths are reported from epilepsy — 13 males and 9 females. Con- 
trary to some authorities, the excess is with the males. , 

Table TIL, Class 4. Diseases of the Organs of Respiration. — The 
deaths under this head foot up 2,915 — a higher number by 20 per cent, 
than the deaths from zymotic diseases. 

The deaths from consumption alone amount to 1,622, or 55.6 per cent, 
of the whole class. For the first six months, under the old law, the deaths 
from diseases of the organs of respiration exceeded those for the last half 
of the year, under the registration law, by 331, or 25 per cent. The excess 
of deaths among males from this class was 89 — equal to 6 per cent. 

The deaths from inflammation of the lungs were 502. In the two last 
quarters of the year, under the new law, they amounted to 191. Of these 
deaths 81 were in the first seven wards of the city. The Second Ward 
yielded 21 deaths, the Seventh 11, and the Fourth 16. These wards are 
more unfavourably arranged and populated for the security of health than 
any other wards in our city. 

The deaths from consumption, viz., 1,622, are nearly 8 per cent, above 
those for 1859, and a fraction below those for 1851 and 1858. 

Of the sexes, the excess of deaths is on the side of females — say 6 per 
cent. As usual, this disease is the cause of a heavy amount of our mor- 
tality, constituting 16 per cent, of all the deaths from registered diseases. 
To the population, according to the last census, they are as 1 to every 350, 
or 2.85 in each thousand. 

The decade of life between 20 and 30 contributed the highest number of 
deaths, viz., 538, or 33 per cent. The heaviest monthly mortality for the 
year appears to have been in February, 116; while November gave the 
least, viz., 106. The previous year November rated the highest. 

Of those deaths registered since July 1st, viz., 192, 419, or 53 percent, 
were native born, and 285, or 36 per cent, were of foreign birth. Of the 
remaining number the nativity was not given. 

Of the wards during the above period, the Seventh, a densely populated 
ward, contributed the heaviest mortality, viz., 48; the Second and the 
Nineteenth each 45 ; the First Ward 39, and the Fifth 31 ; the Twenty-first, 
a rural ward, gave only 14 deaths; the Twelfth furnished 15 ; the Eleventh 
and Thirteenth each 16. These three wards contain a medium population, 
while the Thirteenth rates the healthiest in the built-up portions of the city, 
and is equal in salubrity, according to the register for the last six months, 
to the Twenty -first or rural ward. 

As alluded to in my former reports, croup is steadily on the increase. 
During the year 354 deaths have been recorded from this enemy to child- 
hood — an increase of 42, or 13 per cent, over those for 1859. It furnished 
16.60 per cent, of the diseases of the organs of respiration. The highest 
number occurred in the first quarter, embracing the colder months, amount- 
ing to 121. The lowest number was in the third quarter, viz., 46. 

Table VII., Class 5. Organs of Circulation. — The diseases belonging 
to this class contribute 350 deaths to the annual mortality — 166 males 
and 184 females. 

Under the general term Disease of the Heart there are 281 deaths regis- 
tered, making 19 per cent, of the total. Of these 135 were males and 152 



1861.] College of Physicians of Philadelphia. 



SI 



females. The remaining number, 63, specify the particular name of the 
cardiac affection, from which death occurred. 

Table VII., Class 6. Organs of Digestion. — The deaths from the or- 
gans of nutrition amount to 582, or 5 per cent, of the mortality for the 
year — 310 males and 272 females. The highest number of deaths are 
returned in the third quarter, viz., 209. The first quarter gave only 100 
deaths. The most prominent disease in the catalogue is inflammation of 
the stomach and bowels, which returns 279 of the deaths. Inflammation 
of the liver caused 73 deaths. 

Table VII., Class 7. Diseases of the Urinary Organs. — This class 
of diseases caused 80 deaths in the year; of which 50 were males and 30 
females. 43 of these deaths were under the general term Disease of Kidneys. 

Table VII., Class 8. Organs of Generation. — The diseases belonging 
to the generative system claim to have given 112. All of them except 3 
were among adult women. Puerperal fever contributed 47 — nearly one- 
half the deaths. The first quarter of the year gave 22, and the second 13 
deaths. During the last six months there were only 12 deaths. Cancer 
of the uterus supplied 41 deaths— less by 11 than those for 1859. 

Table VII. , Class 9. Organs of Locomotion. — This class returned 55 
deaths. Of these 22 were from rheumatism, and 26 from disease of the spine. 

Table VII. , Class 10. The Diseases of the Integumentary System 
gave only 2 deaths during the year — 1 from eczema and 1 from elephantiasis. 

Table VII. , Class 11. Old Age foots up 213 deaths, 73 males and 
140 females. As in all vital statistics, the excess of longevity is on the 
side of females. In this instance 91 per cent, were females. 19 of the 
deaths were between 90 and 100 years of age, and 4 were over 100 years. 

Under this head, "Old Age, 7 ' is to be found a convenient hiding-place 
for the difficulty ascribed by some in securing a true diagnosis of the dis- 
eases of aged people. The term is entirely without meaning, and for all 
practical or statistical purposes would answer as well if incorporated under 
the heading "Unknown," Class 13, which gives 134 deaths, and is another 
convenient term employed in too many instances, as in the case of " Old 
Age," to save the trouble of a careful investigation in order to ascertain 
the true cause of death. 

Table VII., Class 12. External Causes. — The deaths from exter- 
nal, accidental, or violent causes always make up a considerable percentage 
of the annual mortality. Eor 1860 they amount to 447, or 4 per cent, of 
the deaths from all causes. 

The great disparity of deaths in this class between the sexes has not 
escaped observation. Those under consideration show an excess of male 
deaths equal to 160 per cent. The male deaths were 323; while those in 
females were but 124. This inequality may be ascribed to the difference in 
occupation with the sexes, and therefore men are far more exposed to 
danger than women. 

The stillborn (Class 14) children for the entire year, as registered, 
amount to 719 — an increase of 61, or 9 per cent, over those for 1859. 
This increase will be found in the first six months of the year, rather than 
in the last semi-annual period under the new law. They constitute 6 per 
cent, of the annual mortality. 

No. LXXXIIL— July 1861. 6 



Transactions of the 



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1861.] College of Physicians of Philadelphia. 83 



Dew-point. 


1 


o 

—1.5 
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42.7 
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Spring . . . 
Summer . . ■ 
Autumn . . 


For eight years. 


January 
February 
March 
April . . 
May . . 
June . . 
July . . 
August . 
September 
October . 
November 
December 



84 



Transactions op the 



[July 



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August 
September 
October . 
November 
December. 


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Months. 




July 

August 

September 

October 

November ..... 
December ..... 




Population of each ward 


Percentage of births to population I 


Ratio of births to population 



1861.] 



College of Physicians op Philadelphia. 



85 



Table II. Marriages. — Number of Marriages Registered under the new 
Law of Registration, from July 1st to December 31st, 1860 ; with the 
Nativity of the Brides and Grooms. 



Birthplace of grooms. 


Birthplace of brides. 


Total of grooms. 


United States. 


Foreign. 


Not given. 


United States 


999 


125 


14 


1,138 


Foreign 


220 


801 


4 


1,025 


Not given 


14 


10 


123 


147 


Total of brides 


1,233 


936 


142 


2,310 



Table III. Marriages. — Ages of Persons Married, and Recorded for 
Six Months, under the new Registration Law, from July 1st to Decem- 
ber 31st, 1860. 





Ages of the females. 




Ages of the 
males. 


Under 
20 


20 to 25 


25 to 30 


30 to 40 


40 to 50 


50 to 60 


60 to 70 


Age not 
given. 


Total 
of the 
males. 


Under 20 


7 


2 












1 


10 


20 to 25 


320 


443 


54 


9 


2 






6 


834 


25 to 30 


102 


354 


143 


32 


2 






2 


635 


30 to 40 


29 


127 


143 


118 


7 


1 




8 


433 


40 to 50 


2 


13 


24 


44 


22 


2 






107 


50 to 60 




2 


4 


12 


7 


4 






29 


60 to 70 


1 


2 




2 


7 


4 


2 




18 


Age not given 


3 


5 


1 










235 


244 


Total of ") 
females / 


464 


948 


369 


217 


47 


11 


2 


252 


2310 



Transactions op the 



[July 



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DISEASES. 


Cancer and scirrhus .... 
" of the breast .... 

" " stomach .... 
" " uterus .... 

Congestion of the brain .... 
" ** lungs .... 

" morbus 

Consumption of the lungs . . 

Disease of the brain . ....... 

" " heart .... 

" " kidneys . . . 



1861.] College of Physicians of Philadelphia. 87 



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DISEASES. 


Marasmus 


Measles ; i 
Maltbrmatiou ...... 

Mortification 

Old age 

Palsy 

Pyohsemia 

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Scrofula . 

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Strangulation 

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Tumours 

Tympanitis 

Ulceration 

" of the stomach and bowe 
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" uterus . 

Unknown 

Worms 

Want and neglect . . . . 


Total, 5,226. 



1861.] College of Physicians of Philadelphia. 



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•rH -rH •COt-n • • -CO • • • -nNIMO) 




•n ( 5[un. 


OS O CM r-H • 


• • rH .COCO^COOO • -r-I • -l-H -rH 


• • rH CO • 00 CO rH • i-H • CM l-H rH • • •COiH-* 


l-H 

> 


Tivn 


•nSiaaoi 


-f CO CO CM i—l 
r-l CO r-l 


. . , H H<Mrt^CO • --^CO • • 'CO • 
1 • • « ri 'H • ■ •• •" 


• rH . lO rH CM H CO rH CM • -CMTf< 'OIMH 


Table 


< 


paruin 


m eo -h • 

ifJCOrt 


rHCMCO ■COO»ffl-f NHONOHC5 •OHrlCCHT(lCOCCOCO • C5CMTt<Tt<CMCMt~00-H/'rHTfl 
.^M^HO CO CM- O-OrH. rH rH J> rH 
rH rH CO i-H 


•zai.it.aoo 


NNrtH J 




• • rH -HNIMH ••!-!••• • i— 1 r— 1 CM • «Q 




•aaoioo 
jo auoaj 


Hffl • • ■ 


• .rH 'lOCOOHt- • 'CM --t r-l 






•asaoHSKiy 






<n to r-t - > :H ■ r-i ^ • ; 












nal) 


jowels 






DISEASES. 




Disease of the brain . 
" " heart . 
" " kidneys 
" " liver . 
" " chest . 


" " lungs 
" " throat 
" " spine . 
" " spleen 

Dropsy (including abdom: 
" of the brain 
" " chest 
«' " heart 

Dysentery . 

Dyspepsia . 

Eczema 

Effusion on the brain 
Enlargement of the heart 
Epilepsy . . . 
Elephantiasis . 
Erysipelas . 
Fever .... 

" bilious . . 

" congestive 


" enteric . 

" intermittent . 

" nervous . 

" puerperal 

" remittent 

" scarlet 

" typhoid . 

" typhus . 

" " icterodes 
Gangrene . i 
Gout .... 
Hemorrhage 

" of lungs . 
* ( of stomach &1 
" uterus 
Hernia 

Hooping-cough . 
Inanition . 

Inflammation of bladder 
" bi'ain . 



34 



Transactions of the 



[July 



•saav,v\ 

XAIOXHKQ 




• • • i-H rH >Q CM • 


■ CO • • ■ 


. . •"OiOrtM • 


rH • ;rH • • 


> © • rH rH CM • 
•CO • 


• rH ; CM • • 


<M 








•HH>5 "ONH 


f OS • ! ■ • 


• rH CM -# <r> • CO 
CM • 


OH -CO ' • 


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• CM • © • • 1 






M 1 




•# CM • 


• OJ • • ■ 


• • • rH © |Hr 


rH • CM rH rH • 


• CM •• rH • • 




CO 




N 


rH 


• • • i-H '(NH • 


■ CM ■ • • 


. . . rH 00 • CM 




• Tf< • rH . . . 


:::-:: 


r~ 




« 




. rH • • • CO CM • 


; 10 '. '. '. 


• • rH -CO • CO 


* ; «H ; ; 


• rH •■ CM • • 




!M 




o 

« 1 




• r-^r-, .OJ . . 


. OO rH • ■ 


• • rH CO rH • CO 


CM • rH rH CM • 


•-P • • rH CM ■ 


. • rH CM ■ rH 






o 

rt 


cm 


• rH ■ CI «5 • 


HM • l-H • 


• CM rH CM CD rH >Q 


IC5 • • CO CO rH 


• OS ' r-< CT! r-l r-t 


: : : 


(M 
■Q 




OD 
H 




• i-h • cm • oo cq . • 


.■ ° '. '. ; 


• • • • CO CO 


CM • rH CM • • 


•CO 




CM 






CO 


. rH • • • CD rH • 


ri«S .• • 


• • • O -f CM 
... CM 


•CM rH rH rH CO • 


• CM • CM CO • rH 


• • 


CO 




o 




. . • rH ■ CO • • 


• xHrH • ■ 


• • • rH IQ -CM 


■CO • • CM rH • 


• CO • • • • rH 


,HH^ • • 








CM 


• • !M CM • CO rH • 


• 00 rH r-i • 


rH rH • CO CO rH CO 


. rH CO • ■ 


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• • rH CO • • 


CO 
CM 


CO 

P 


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•rH • • 


o 


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M 




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CO 




5? 
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rH ... CO • CO 






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CM 
oo 




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• CO • r-t r-t i-t • 


■ t~ • • rH • • 


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CM 








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• CO • • • l-H • 


• • • CO • • 


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- 


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.[>..•• 


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• rH 




© 
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. O0 • -rH 


• CM • CM !M • GO 




■ C3 ■ CM CO • • 


rH • . . 


CO 
CO 




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1-1 N '. '. '. 


.... OJ -CM 




. co ••■-*• • 








115 




. . rH . . -H* . 


. O • • • 


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• IQ rH • • rH • 


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• rH • CO • rH 


1 








• -CMrHrH OCM • 


•oo ■ ; • 


• CM • CO © -CO 


■ rH • CM CM CO • 


• t~ rH CM • • ■ 

• CM . . . 


• l-H • C5 • • 


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. rH • • • O rH 


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• CO -r-l • . 


• rH • IQ • • 


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CO 
1 CM 




« 


i 


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• Ci • rH 


• ;H»N ■ • 


•CO • • CO rH • 


-CO • • CO 




1 CM 

1 £3 




H 


r 


: : :« 


rH JD~ 


• • -co © -co 

... CM • 


■ • • ■* IQ rH 


rH CO • rH r-l CM • 
CM • 


rH •• CO • • 








CM 


. • -CM • rH CM 


• CO • • 


• rH • O0 CO • >© 


• CO rH rH IQ • • 


;HHH • CM • 


• rH ■ -H* • - 


CO 
IQ 
CO 


TIVIT 


•uSia-io^ 


l 03 


rH rH rH CM CM CM -H CM -tf £• • CM 
rH CO CM CM • 


CO CM CO 00 CO CM O 
CM rH CO 


• • CM CO rH CO 

• CM • 


C~ IQ 


• rH -CO • • 


II 

1 2 






SO 


• o OO CO CM co eo rH 


• © -# CM rH 

• CO 


• t>H(H'rja;-i<(MN-to>o»w 

rH © CO 


rHCD^t^-fcOCOCMOO-^^CMCM 

co 1-1 


oo 
co 
oo 




CM 




; '. ° i '. 




• CM • rH rH • . 






CO 


•HI1O1O0 

jo aiaoaj 




• > • CM 


. to • • 


... .tt -CM 
... .CM • 


• CM rH CM CM • 


• © • CM rH rH • 




© 

CO 


•afr-flOHSKIV 




. • -CO • © l-H 


j ; 


• r-l • CO O -CO 


• CO rH -CO • • 


• rH CO rH • rH . 




Is 

1 CM 








jowels 








• • 





a? » 2 P 2 



O Sh 



J S rH Pm^S P, CD ^ S r5 



o 
p. 

2 c3 



CD o 
jH to 

- 8 



09 S 
' O 



5 ii-i^ if &i l^f ss S 1 1= 1 1| 



MhSSS^O^i Pn'rH M OG X X X X ' ^- E- Eh H S 



1861.] College of Physicians of Philadelphia. 95 



IQ CO CO rH CO CO i 
O 01 



CD C IM » N S 



oo ■ c~ r-- "o 



tO '(MM ■ rH 



^ N :■: s -#i 



rH o t~ co «o <m cq 



o co oo cm i 



(M • l-l rH 



<M CM CO "* r-l OO 



N CO O 3 



• r-l CO CO 'CO 



5 8 <D 53 "o 



CO CM CM rH rH 



« « w .3 s- 



O O 03 j 
rO O O 6£).i 



|0 PPPWrH 



o O ci 3 
,C ,£ - o 
3 ft ft- ? M o 

ft"* ^2 =J 

- - - - o o 5 

K *3 CG co E~i 



• CM • <M O • rH 



^ • cq >o co co . 



N rt 3 H N O 



CM -IMNia 



zn s 
zr. S 



>> 53 .i !h 
UPrHrH 



96 



Transactions of the 



[July 





OtOMCOt- lTjHCO00C0CqrHt^©CO»O© 
<M CO CD t-» I> <M Cq i-H 
r-l TP 


1656 


eo-Hcocqt>t~©cq©©t^cq©©i— i 
o i— i io-+ | t^cq©r-irH co cq 

l-H C4 >Q r-i CS1 rH rH 


1966 | 


Dec. 




. . >C q .-Hrjicq • -r-i ;rH • • ; • 


cq 

CD 


i-H rH © .r^Cfir-i • «Q . . «J . . 


t~ 




COrH • CD ; 


CO 


© t- co • go © eo rH © i-h »o • cq cq • 




> 
o 


Ph 


. . •■ -COIS. • • 00 • rH ••• 


© 


CO © >0 • •QOHMHOH • 


© 




• • 'NH -CD-* • • IO • -r-l • Cq 


CO 


©©© • rH CO rH -rH -CO • © CO • 


CO 


Oct. 


Ph 


. . .CO • -COO • -CO • • <N • 


~. 

CO 


t> © CO •!>©© -©CO • • t- • • 






<M . .CO • • IO • • (N -CM • -r-l 
. . . . cq . . . . . 


© 


S rH N IrHrH^' - '^ ' rH 1*°° • ^ 


© 


Sept. 


Ph 


'. '. '. 1—1 '. '• l ^ §q '. '. 1—1 • 1-1 '. '. '. 




Tj<©Cq • CO © Cq i-H i-H rH rH • CO -rH 

cq • ■ 






•r-l • CM • CO CD © • • CO -CO • • • 

CO 


© 

GO 


© o io -non -t> • io 




August. 


Ph 


I-I • -r-l • •t>t^r-l • CO • • l-H • • 
. . . . CO • . . . . 


© 

© 


^ rH Cq " N rH 00 ^ rH 1-1 " 10 ' 1-4 


© 




<N • • r-l • • O GO • • © ■ CO r-l • rH 
• • ■ • rH O • • 


cq 


CqCOCOrHr-OCOrH© .©l-H© -CO 

rH cq cq i— i i-h cq • 


© 


July. 


Ph 


rH rH . .io -NN • • 


© 


TfNH ;©©CqrH© •© -rH 


© 




CO • • CN • • r- © • .CO . Cq rH • • 
• • • • rH O • • ■ • • 


© 


©© Cq rH rH CO -CO •© •© • • 

cq i— i i-h . i—i • . • ■ 


© 
© 


June. 


Ph 


. . -rH . .tJ<1> i .N rH i • ♦ • 


© 


co © • co © o cq co rH cq • • 






. . • (M ■ • CO -H rH • CO • • rH • • 


© 


th i-h -fj • co o cq cq • © .t> • • 


00 


tn' 

<! 


Ph 


rH ..(M..O J t-....rHrH - ; 


CO 

© 


«5 © rH • cq t~ CO l-H 1Q • >Q 'CO • • 






rH . • « • • t?- os • • i-h • cq - • • ■ • 




© © H -©COrHCq© •« •■<* • • 


© 
CO 


April. 


Ph 


. • , • CO • • © r-l • 


CO 

o 


• © © l-H l-H CO • IO • . . 


© 
© 




rH • • Oq • • O rH • • CO CO l-H • • • 




•O rH GO * © CO O rH CO •© • t- • Cq 


© 


March. 


Ph" 


■ rH rH i— I • • rH CO • • -^rH .... 


© 


co © © • iq -# •© -co • . . 


© 




CO CO • • • (M -rH • rH 




>0 Tj< 00 • t~ •*♦< (M © • rH • . rH 


© 


B 
W 

Ph 


PH 


CO • rH • • -HHCOH ■HlOH • • rH 




(SIOH • CO IO © rH © rH rH • 1Q • CO 
rH CO • rH • 


© 




i-KN • CM • • Jt~ i-H . . t}< IQ CO . . . 


© 


io cq © • t- >o i-h cq rH i-h cq -co • • 
i-h cq • rH cq 


© 


Jan. 


Ph 




© 


^ go co • >a © cq • rH • co • cq 


00 

© 




rH ©© • Cq rH • rH CO • 


© 


© IO © • t~ © • rH H -CO • O • rH 




DISEASES. 


CLASS II.— Uncertain or General Seat Sporadic 
Diseases — continued. 

Gangrene 

Gout 

Hectic fever 

Hemorrhage 

Inflammation of leg 

M throat 

Inanition 

Marasmus ....... 

Malformation 

Mortification 

Scrofula 

Sore throat 

Tabes inesenterica 

Tumours . 

Ulceration 

" of throat 

Total 


CLASS III.— Nervous System. 

Congestion of the brain 

Coup de soleil \ . 

Dropsy of the brain 

Epilepsy 

Inflammation of the brain .... 

Softening of the brain . . 

Total . . 



1861.] College of Physicians of Philadelphia. 



91 





CMCSCM-HrHrHCOr~t~rHCO'MCO 
CO CM CM O -*J CM © MOH 


1? 

ri 


TP Ml «5 Q O 
00 CO rH 


© 


NOH/lOHHt-H 

CM 


p 
P 


Ph 


^^SS ; rtM • * -co • 


CO 


•r-l 








N 50 CO CM • • ^ • °° • N H H 


§3 








o 
& 


rH 


• N toH • • 1-1 ; 00 1-1 ^ ^ . 


OS 


• rH 








•COO-H • -rH -CO • CM CO CM 
Tf< CM • • • ri 


CO 

OS 


• rH 






Oct. 




• 00 CO © • • CM • 1Q . rH © • 
,_, . . . CN • 


-1 


• rH 






a 


co co o cm • -thcmco • cm t~ • 

O CM ■ • CM • 


CM 
CO 








Sept. 


ph 


■00)1> • • CO rH r-l • • rH . 
«5 • • • • rH • 


r-- 

co 










rH rH CD OS • •-H^rHCM • -CD ' | 








A ugust. 




CM CO CO -HH • • t- rH CM • rH CM • 
CO ■ • rH • 


CM 


• OS rH • • • 


o 




g 


HI>NCOH 'i-i-fH 
I- • rH • rH 


CO 


• CO *Q • -rH 


OS 




July. 


Ph 


• i-H CO CO • • © • • • • • 


OS 


rH OS .... 


o 

CM 






H "*OH • • rH • • ■ 33 • 


os 

OS 




OS 




H 
r-5 




CO Tt< O CO • •t^(M-*l • rH OS • 
«5 • • rH ~ • 


CO 


. co • • • • J CO 






• O CD ~H • • CD • -HH . .COH (M 
OH rH © 


• CO ... . 


CO. 




May. 


Ph 


CM rH O CM • •© -^1 .^COH 
HGH • -H • • CM 


J>. 
o 










CM IQ CM CO • • CO rH Tt< • CO O • 
t» i— 1 • • CO ■ 




• CM rH • • CM 






April. 


Ph" 


rH (M -f CO • -CD • CM 'HON 
CO rH . . . • CM 




ft) 






HfflOQ • . OS • ■* • CO CO • 








March. 


Ph' 


HH/OO • ■ CO CM IO • CM CO ' 
t— 1 rH • • rH • 


- 


• O • • • rH 


CD 






CMCOCSCO • -COHN -OCM • 
COH • • CM • 


co 




CO 

© 
-1 




Ph 


Pm' 


COGCN • • CM CO • CM 00 rH 
CO CM • • rH • CM 


• 00 . CM • • • 






<M CO to CM • • CM O • CM CO CO 
rH OS CO • ■ -CO 




5s 


^cm""" '• '• 


CM 




«! 

1-5 


- p=l 


H^OO • • CO -tf • CO Hjl ^ 


CO 


• CM rH . • • 


CO 




a" 


HNOO • • CD CM © ■ rH t- • 
O CM • • rH ■ CO • 


oo 


CM • • rH 






DISEASES. 


CLASS IV.— Diseases of the Kespiratory System. 

Asthma . 

Congestion of the lungs 

Consumption of the lungs 

Croup . . . . . • • • 1 

Disease of the lungs 

" " chest 

Dropsy of the chest 

Hemorrhage of the lungs .... 
Inflammatiou of the bronchi . ,. 

" " chest ... . .. 

[[ • " larynx . . . 

" " lungs 

" " pleura .... 


o 


CLASS V.— Organs of Circulation. 

Aneurism . 

Disease of the heart . .. ...... 

Dropsy of the heart ..... 

Enlargement of the heart ..... 

Inflammation of the heart .... 

Pyohiemia . 

Total 


CLASS VI. — Diseases of the Digestive Organs. 
Cancer of the stomach and bowels 



No. LXXXIIL— July 1861. 



98 



Transactions op the 



[July 




1861.] College of Physicians of Philadelphia. 



90 




100 



Transactions or the College of Physicians. 



[July 



Table YIII. — Mortality in each Ward, with the Population, according to 
the late Census, with the ratio of Deaths to Population, and the Per- 
centage of Deaths in each Ward to the Total Mortality. 



WAKDS. 


Population 
last census. 


Deaths. 


Deaths to 
population. 


Per cent, of deaths 
to total mortality. 


First .... 


37.078 


448 


1 


in 83 


7.07 


Second . . . 


23,097 


332 


1 


<• 69 


5.23 


Third .... 


19,976 


237 


1 


" 84 


3.71 


Fourth. . . . 


23,633 


385 


1 


" 61 


6.06 


Fifth .... 


24,858 


232 


1 


" 107 


3.65 


Sixth .... 


14,928 


150 


1 


" 99 


2.36 


Seventh . . . 


31,397 


358 


1 


' £ 87 


5.64 


Fighth . . . 


27,811 


190 


1 


" 146 


3. 


Ninth .... 


17,215 


182 


1 


" 94 


3. 


Tenth . . . . 


21,967 


214 


1 


" 102 


3.37 


Eleventh . . . 


16,717 


182 


1 


" 92 


3. 


Twelfth . . . 


16.811 


158 


L 


1U ( 


' 2.45 


Thirteenth . . 


20.132 


123 


1 


" 163 


2. 


Fourteenth . . 


24,336 


195 


1 


<< 124 


3. 


Fifteenth . 


32,431 


283 


1 


" 114 


4.46 


Sixteenth . . . 


20,092 


194 


1 


" 103 


3. 


Seventeenth . . 


23,328 


307 


1 


" 76 


4.84 


Eighteenth . . 


20,470 


217 


1 


" 93 


3.42 


Nineteenth . . 


39,271 


452 


1 


" 87 


7.12 


Twentieth 


30,152 


261 


1 


" 115 


4.04 


Twenty-first . . 


17,164 


1 99 


1 


" 140 


2 


Twenty-second . 


17,286 


147 


1 


" 117 


2.*31 


Twenty-third . 


24,093 


187 


1 


" 129 


3. 


Twenty-fourth . 


23,791 


190 


1 


" 125 


3'. 


Unknown . . . 




224 








Almshouse . . 




243 








From the country 




131 








Total for 6 mos. I 

Total population 1 568,034 
Total mortality for the year 
Ratio of deaths to population 


6,342 
11,568 


1 


in 51 





1861.] 



101 



FISKE FUND PEIZE ESSAY. 



Art. IX.— On "The M&fbid Effects of the Pretention in the Blood of the 
Elements of the Urinary Secretion." By Wm. W. Mokland, M. D. 
(Continued from April No. p. 460.) 

Rheumatism. — Nearly related to gout is the disease known by the term 
rheumatism; an affection which, like its congener, may be acute or chronic, 
and is characterized by very similar constitutional symptoms and by many 
local phenomena of like nature, while yet there are several striking points of 
difference. Thus, we observe indications of irritative action and of 
inflammatory states of variable severity ; fever, anxiety, restlessness, chills, 
with full, quick and sharp pulse; gastric and intestinal disturbances; thirst, 
white tongue, foul breath, and acicl eructations. Locally, there is heat, 
pain, and tense, or sometimes doughy, shining redness, with swelling around 
certain joints, and often affecting neighbouring tissues, as the muscles, 
tendons, &c. By preference, the larger joints are attacked in contradis- 
tinction to gout, which, as we have seen, fixes upon the smaller. There is 
also the remarkable and very distinctive symptom, or rather local mani- 
festation, of acid perspiration, often very profuse and offensive. The 
latter is apparently the corresponding fact, so to speak, to the local 
appearance of urate of soda in the tophaceous deposits in gout ; for, in 
true rheumatism, nothing of the sort occurs; in rheumatic gout, as will 
be seen, there is an analogous deposit. 

From what we have already indicated, it is not difficult to see a great 
resemblance between gout and rheumatism ; they have indeed been denomi- 
nated "first cousins." The first and most important question for us, con- 
cerning rheumatism, is — and it is an inquiry of great practical interest — 
does it depend upon excess of uric acid in the blood, and its retention 
therein ? 

The latest views of the pathology of the disease seem to give a directly 
affirmative answer to this question ; and, of course, under this aspect of 
the subject, it devolves upon us to enumerate the affection and its results 
amongst those "morbid effects" of retention in the blood of the urinary 
"element" we are now examining. It should, however, be distinctly pre- 
mised, that many researches and much close study and observation are yet 
required in order to enable us positively to declare uric acid or any of its 
products to be the materies morbi in rheumatism. Observers, however, at 
the present day, at least begin to speak with more confidence and decision 
upon this point. In the first place, we find it more than ever common for 
systematic writers on medicine to consider gout and rheumatism under one 
head ; often in one chapter. Next, if we examine the language employed 
in discussing the yet unsettled question as to the essential cause of the 
disease, we shall observe a tone of much greater decision than in the works 
published only a comparatively short time since ; while the matter is yet 



102 



Morland, Uraemia. 



[July 



left open to doubt — most authorities not fully compromising themselves. 
We will refer to a few of these opinions. Dr. Barlow {Manual of the 
Practice of Medicine, 1856) says : — 

" The external cause [of rheumatism] is generally exposure to cold, especially 
when producing repressed perspiration. Its internal or essential cause seems to 
be an abnormal condition of the blood, which contains always an excess of 
fibrin and of uric acid : the latter is probably the materies morbi or peccant 
matter." (p. 130, op. cit.) 

Dr. Bennett {Clinical Lectures on the Principles and Practice of 
Medicine, American edition, 1858) begins his remarks upon the General 
Pathology of Rheumatism, and Gout, as follows : — 

"The present theory with regard to these affections is, that they are both 
connected with an increase of lithic acid in the blood. In rheumatism, this is 
dependent on excess of the secondary, and in gout on excess of the primary 
digestion." (Op. cit., p. 909.) 

The latter author also refers to the fact that a considerable amount of 
lactic acid is excreted from the skin, as was taught by Prout, and men- 
tioned by Todd, Watson, and others of note, who have carefully studied 
the subject. Hitherto, the tendency seems rather to have been to ascribe 
the morbid phenomena of rheumatism to an excess of the last named acid 
in the system. Dr. Prout, in the fifth edition of his celebrated work on 
Stomach and Penal Diseases, refers pointedly to this explanation, as being 
his own belief. While mentioning in a foot-note (p. 549) the opinions of 
Dr. Garrod as to the relations of uric acid to gout and rheumatism, he 
says : "In various parts of this work I have spoken of lithic acid as being 
characteristic of gout, and the lactic acid of rheumatism. At any rate, I 
agree with Dr. G. that lithic acid has little to do with pure rheumatism ; 
though it is often present in what is called rheumatic gout." In the latter 
affection — which is understood to be that variety of gout which attacks all 
the joints, indiscriminately, and for which Dr. Todd prefers the name of 
"general gout" — it is natural to believe that the chief morbific agency is 
uric acid, or a salt from it. It has, however, as we previously stated, until 
somewhat recently, been the persuasion of the majority of observers that 
lactic acid held that relation to rheumatism, which it seemed plausible to 
assign to uric acid in reference to gout. In his last edition (1857), Dr. 
Watson says, in the course of a remarkably clear and accurate resume of 
the distinctions existing between gout and rheumatism {op. cit., vol. ii. 
p. 761, English edition) : "Gout is often, rheumatism is never, associated 
with chalk-stones ; and conformably with this distinction, Dr. Garrod has 
taught us that uric acid in excess is present in the blood of the gouty, and 
not present in that of rheumatic patients." 1 

The manner in which Dr. Todd {op. sup. cit.) refers to the method 
pointed out by Dr. Garrod for detecting uric acid in the serum of the 

1 Speaking of Dr. Prout's belief in regard to the lithic and lactic acids, and their 
relations to gout and rheumatism, Dr. Watson relates certain experiments, by Dr. 
Richardson, upon animals. Lactic acid introduced into the peritoneal cavity of a 
healthy cat, produced irregular cardiac action in two hours. The animal was 
found dead the next morning, and no peritoneal inflammation was discovered, but 
"marked endocarditis of the left chambers of the heart. The mitral valve was 
inflamed and thickened, and covered on its free borders with firm fibi'inous 
deposits. The whole inner surface of the ventricle was highly vascular." Similar 
results were observed in a dog experimented upon in like manner. No textural 
alterations were found in the joints. 



1861.] 



Morland, Uraemia. 



103 



blood, in gouty cases, seems decidedly indicative of his own views as 
respects the existence of uric acid in excess in the blood in gout and not in 
rheumatism ; and in this connection, we are glad of an opportunity to give 
the method of Dr. Garrod, above referred to. Dr. Todd says : — 

" Dr. Garrod has made out a positive physical character of gout, which may 
be regarded as surely diagnostic of that disease from rheumatism. It consists 
in the discovery of uric acid in the blood-serum or the blister-serum. And his 
process is ingenious, and so simple that any one may use the test, however little 
accustomed to chemical manipulation. A little serum is put into a watch-glass, 
and to it are added five or ten drops of acetic acid. In this acidulated serum a 
small skein of worsted is laid, and the watch-glass is set aside under cover to 
protect it from dust. After a few hours, the crystals of lithic acid, if it exist, 
will be found adhering to the threads." 1 (Op*. cit., pp. 408-9.) 

Dr. Henry William Fuller, of London, Assistant Physician to St. 
George's Hospital, in his very scientific and able treatise on Rheumatism, 
Rheumatic Gout, and Sciatica, published in 1852, takes the ground that 
lactic acid is the materies morbi in rheumatism. He thus falls in with 
the opinions of Drs. Prout, Todd, Williams, and others, who so believed, 
although not positively asserting the fact as indisputable. Dr. Fuller con- 
siders the cause of the disease to be a poison in the blood, and which is 
generated in the system as the product of a peculiar form of mal-assimi- 
lation — of vicious metamorphic action. This poison it is "which excites 
the fever, and produces all the pains and local inflammations which are 
often found associated in an attack of rheumatism." {Op. cit., p. 28.) He 
then points out the fact that although the fever may be increased by the 
occurrence of the local inflammations, "it is essentially independent of 
them," and often is well developed before they begin. If the virus is in 
small quantity in the blood, then only slight wandering pains are produced ; 
if in large quantities, and increasing, the effects are usually proportionate. 
Some constitutions, of course, manifest more resistance than others. 

We have previously cited the authority of Dr. Garrod in reference to the 
morbific agency in gout and rheumatism ; and in his late work, 3 we find 
him reiterating his views, and pronouncing the urate of soda 11 pathogno- 
monic" of gout. Some of this author's conclusions thus lately arrived at, 
or rather confirmed — for such, we believe, has always been his doctrine — are 
so positive and so much to the point for our present purpose, that we quote 
them. His analyses show that " healthy blood contains the merest trace 
of uric acid or urea, so small as to be in general undiscoverable, except by 
the most minute and searching chemical examination, and not always then. 

" That, in gout, the blood is invariably rich in uric acid, which exists in the 
state of urate of soda, and can be separated from it, either in the form of the 
crystalline salt in acicular needles, or as rhombic crystals of uric acid. 

" That, in acute rheumatism, the blood is free from uric acid, or, at least, 
contains no more than in health. 

" That the perspiration seldom contains uric acid ; but that, in gout, oxalate 
of lime may be crystallized from it, as also from the blood." 3 



1 In Dr. Garrod's late work ( Gout and Rheumatic Gout) we find this process 
much more elaborately described. See pages 110-113, op. cit. 

2 " The Nature and Treatment of Gout and Rheumatic Gout." 

3 In giving these opinions of Dr. Garrod, we followed the statement furnished in 
the Lancet of December 24th, 1859, not then having seen Dr. G.'s work. The ac- 
count is by the Reviewer, condensed from the book itself. We have lately, how- 
ever, had the volume at our disposal, and can testify that it is a most satisfactory, 
complete, and erudite treatise. 



104 



Morland, Uraemia. 



[July 



In the above expressions of opinion, founded on careful analysis, we find 
Dr. Garrod distinctly declaring that the blood is free from uric acid, or 
only contains a normal amount thereof ; he therefore does not consider 
that acid the cause of rheumatism. 

Such are some of the opinions to which we referred ; and while, in view 
of the existing difference in the decisions of equally eminent men upon this 
poiut, we cannot look upon the pathology of rheumatism as by any means 
definitively settled, it seemingly devolves upon us to consider the disease as 
a condition referable to excess of uric acid in the system, in deference at 
least to the opinion of many of the latest observers, whose position, judg- 
ment, and opportunities for the accumulation and weighing of evidence are 
such as to entitle their announcements to the greatest respect. In this 
regard, however, as much can be said for those who hold the opposite 
views, or who do not fully compromise themselves; but we shall be quite 
safe, at least, in discussing the question according to the plan above an- 
nounced. Our own conviction, hitherto, has always been wholly in favour 
of the lactic acid theory ; and, within a day or two, having put the ques- 
tion to a highly-cultivated and well-informed medical friend — "What do you 
consider the materies morbi in rheumatism to be ?" his reply was, after a 
few moments' consideration, " Some product of lactic acid— some of the 
lactates." 

Whatever the fact may be, it is clear that the fault of deficient excretion 
is equally active in rheumatism as in gout ; the former is as distinctly a 
blood-disease as the latter. 1 The deranged excretory function (" Uric-acid- 
excreting"), however, chooses a different field for the manifestation of its 
disorder or impairment ; the disarranged balance between the excess of acid 
and the excreting power being as evident in one as in the other. Dr. Ben- 
nett (op. cit.) writes very clearly and comprehensively on this point. He 
remarks : " In both diseases there is an undue balance between the excess 
of lithic acid and the power of excretion — in rheumatism by the skin, and 
in gout by the kidney. This pathology serves to explain the similitudes 
and differences existing between the two affections. In both there is a cer- 
tain constitutional state dependent on deranged digestion, during which, 
exciting causes occasion local effects." 

He then signalizes, the fact that in rheumatism the exciting causes are 
those of a depressing nature, and are usually exerted upon the poorer 
classes. The chief provocatives of rheumatism, as is well known, being 
cold and wet, bad and insufficient food, and hard labour. As we have 
already set forth, precisely the opposite immediate causative elements are 
active in gout, i. e., luxurious and intemperate diet, indolence and self- 
indulgence of all kinds. Dr. Fuller's idea — and which is, doubtless, that of 
every reflecting and intelligent practitioner — is, that the morbid material 
acting in the blood, is often, if not nearly always, the sole cause of rheuma- 
tism — secondary or exciting causes not coming at all into play, or proving 
ineffective, if brought to bear on the system. They are only promotive 
agencies, not causative elements. 

It will not be expected of us, we conclude, specially to detail the course 

1 " In truth, acute rheumatism is a blood-disease. The circulating blood carries 
with it a poisonous material, which, by virtue of some mutual or elective affinity, 
falls upon the fibrous tissues in particular, visiting and quitting them with a va- 
riableness that resembles caprice, but is ruled, no doubt, by definite laws, to us, 
as yet, unknown." (Watson, Practice of Medicine, vol. ii. pp. 738-9.) 



1861.] 



Morland, Uraemia. 



105 



of rheumatic fever, or of chronic rheumatism. Indeed, with the present 
undetermined state of the pathology of the disease, we might perhaps have 
darned it justifiable to withdraw the disease from the category of the 
"morbid effects" of retention of an element of the urinary secretion in the 
blood. It could hardly, however, be other than an omission of some moment, 
had we not carefully examined the present belief on the subject ; and, hav- 
ing done this with considerable research, we place in due order the names 
of all the authors of most eminence in regard to the subject, within the 
last few years, whose works we have been able to consult, Their opinions 
are expressed with more or less positiveness ; some only implying their 
belief, others boldly asserting it. 

What is the Materies Morhi in Rheumatism ? 



LACTIC ACID. 

Dr. Front .... (1848.) 

" Fuller .... (1852.) 

" Todd .... (1857.) 

" Watson .... (1857.) 



URIC ACID. 

Dr. Barlow .... (1856.) 

" J. H. Bennett . . (1858.) 

" Copland . . . (1858.) 

" Thudichum . . . (1858.) » 



With respect to Drs. Thudichum and Golding Bird — the latter of whom 
might have been ranged with the former in the above table — their opinions 
are inferred from expressions in their works, such as we quote in a foot- 
note. 2 

It may here be added that Dr. Prout intimates it to be a very suppo sable 
and plausible doctrine that the phenomena of rheumatic gout — which, by 
the way, both he and others pronounce very difficult to relieve — may be 
explained by the fact of the concurrent action of both lactic and lithic acid 
in the system. This form or combination of disease requires to be de- 
scribed more at length, as being less familiar than rheumatism, and pre- 
senting more novel points for inquiry. 

Rheumatic Gout. — We have already referred to this affection, which 
presents a singular combination of the characteristics of rheumatism and 
gout. Without resembling either, as a whole, it partakes, seemingly, of 
the nature of both. Unlike gout in general, it attacks the weakly individual 
as well as the strong, and quite as readily; or else those who are robust, 

1 Dr. Grarrod might, by inference, be placed in the left-hand colnmn ; since, al- 
though he does not, so far as we have been able to ascertain, say that rheumatism 
depends on the presence of an excess of lactic acid in the blood, he demonstrates 
the absence of uric acid in the cases he has examined, and evidently does not con- 
sider it, in any wise, dependent thereon. (See his late work on The Nature and 
Treatment of Gout and Rheumatic Gout.) 

2 " In the two allied affections, gout and rheumatism, exclusive of the many 
neuralgic diseases popularly referred to the latter, a remarkable tendency to the 
formation of an excess of uric acid, both pure and combined, occurs." G. Bird, 
Urinary Deposits, English edition, by E. Lloyd Birkett, M. D., 1857, p. 150. 

" As a question clearly put is half the answer, we may be permitted here to con- 
sider what proximate conditions of the system a rise or fall in the quantity of uric 
acid beyond the normal limits is likely to indicate. A deficiency may be due to 
a diminished production in the system, as in ansemia, or to retention, as in certain 
stages of gout and rheumatism. It is at least questionable whether the retention 
is ahoays due to diseased action of the kidney. Any disease, however, which in- 
terferes with the secreting power of the kidney by changing its structure, such as 
Bright 's disease, is certain to cause retention of uric acid in the blood, in propor- 
tion to the retention of the other constituents of urine. (Scarlatina seems to make 
an exception. * *.") Thudichum, op. cit., p. 95. 



108 



Morland, Uraemia. 



[July 



when either physically or mentally depressed. In this malady the analogy 
of the two diseases is most apparent ; or rather, their dependence upon a 
similar cause is perhaps most clearly seen. We observe, however, that J)f. 
Garrod, in his work just published, 1 does not incline to the idea that this 
affection is actually a combination of gout and rheumatism. He prefers, 
moreover, to employ the term "Rheumatoid Arthritis, 11 and remarks: 
" If we agree to name a disease simply from its external characters, then I 
admit that the term rheumatic gout is not inappropriate ; but if we advance 
further, and have regard to more intimate pathology, then I deny the pro- 
priety of the name : acting upon the former principle, we should be equally 
justified in calling some cases of scarlatina or measles by the compound term 
of rubeolo-scaiiatina, and we know that these diseases were not separated 
two centuries ago * "Although unwilling to add to the number 

of names, I cannot help expressing a desire that one might be found for 
this disease, not implying any necessary connection between it and either 
gout or rheumatism. Perhaps Rheumatoid Arthritis would answer the 
object, by which term I should wish to imply an inflammatory affection of 
the joints, not unlike rheumatism in some of its characters, but differing 
materially from it." (Op. cit., pp. 533-4.) Dr. Garrod also refers to the 
fact that but few authors recognize any existing combination of gout and 
rheumatism, many even strongly oppose such a doctrine. He mentions 
Boerhaave, Yan Swieten, Cullen, Heberden, and Watson, as not alluding 
to such a connection or fusion, and quotes Sir C. Scudamore, as saying 
"that the textures which have been long affected with gout, become so 
much weakened as to be very susceptible to vicissitudes of temperature ; 
and in this way the general disorder may partake of rheumatism. It was 
only thus that he could attach any propriety to the very common expres- 
sion rheumatic gout. It would appear that the term is often made use of, 
but seldom attempted to be defined with precision." (Op. cit., p. 52T.) 

The affection has been known by various names. Thus Dr. Haygarth 
styled it "Nodosity of the Joints ;" Cruveilhier, " Usure des Cartilages 
Artie ulaires ;" Dr. Adams, of Dublin, 11 Chronic Rheumatic Arthritis. 11 
Dr. Garrod, who mentions the above designations, also says : " It has 
sometimes received a name dependent on its situation ; for example, rheu- 
matic gout, when the wrists, hands, and feet are affected ; chronic rheuma- 
tism, when in the shoulder, elbow, or knee, either singly or simultaneously; 
and morbus coxae senilis, when located in the hip. Occasionally it assumes 
an acute, or rather subacute, character, but more generally it is chronic 
throughout." (p. 533.) 

Neither sex nor condition in life seems to have any influence in procuring 
immunity from this disease. According to Dr. Adams, the hip-joint is 
most often affected in males ; in females, the wrists and hands. He found 
it more prevalent amongst the poor and labouring classes ; Sir Benjamin 
Brodie considers it most common in the higher classes. This diversity of 
opinion, Dr. Garrod explains by referring it to the " difference in the class 
of cases more prominently brought under each surgeon's notice." (Op. cit., 
pp. 534-5.) 

The main characteristics of the disease may be grouped as follows : 
Pain, of a migratory nature, and which is often very severe and obstinate. 

1 The Nature and Treatment of Gout and Rheumatic Gout. By Alfred Baring 
Garrod, M. I)., F. R. S., Fellow of the Royal College of Physicians, Physician to 
University College Hospital, etc. etc. ; London, Walton and Maberly, 1859. 



1861.] 



Morland, Uraemia. 



10Y 



It is sometimes aggravated at night, and also by heat. (Garrod.) Motion 
is extremely painful to an affected joint, especially after prolonged rest. 
There is notable frequency of recurrence, and predilection for the smaller 
joints. The joints attacked become, after a time, swollen ; fluid is effused 
in considerable quantities into the cavities of the joints, and fluctuation is 
often perceptible. The ratio of helplessness is, of course, in relation with 
the number of joints crippled ; generally, none of the articulations escape, 
when once any of them have been invaded. There is usually but little 
accompanying febrile excitement and constitutional sympathy ; although 
this depends, very distinctly, upon the number of joints attacked ; that is, 
upon the extent, or degree of universality of the disease. (Auct. cit. et al.) 

Complications. — Cerebritis, pleuritis, inflammation of the eye. The latter 
is comparatively rare ; all the ocular tissues may be affected ; generally, how- 
ever, if the patient have treatment, the choroid coat and the iris escape. 
Exhausted and shattered constitutions are those most obnoxious to ocular 
inflammation in connection with rheumatic gout. (Fuller.) 

Results. — Thickening and permanent enlargement of the structures 
forming, and (less frequently) of those surrounding the joints ; occasionally, 
there is cuticular desquamation, as in gouty cases. In the chronic form, 
which, as we have stated, is most commonly observed, the articular carti- 
lages are affected, the ligaments about the joints are stretched, and the ends 
of the bones are irregularly enlarged. The synovia subsequently becomes 
absorbed, and the capsular membrane is left much thickened. The liga- 
mentum teres of the hip, and the tendon of the biceps are sometimes de- 
stroyed, and even completely removed. Not only the articular, but the 
inter-articular cartilages are absorbed; this is observed in the knee-joint, 
the wrist and the lower jaw. (Garrod.) When the disease has been very 
prolonged and severe, the synovial membrane becomes not only thickened, 
but droops into the articular cavity ; or, as Dr. Fuller points out, " a 
dense, ligamentous substance, resulting probably from some peculiar altera- 
tion in the synovial membrane, is seen interposed between the articulating 
surfaces ; or small irregularly shaped cartilaginous bodies are found, either 
loose within the joint, or attached to it by pedicles formed of thickened 
synovial membrane." Sometimes these excrescences are bony ; and others 
of a vascular nature likewise exist. (Garrod, op. cit.) The opposite sur- 
faces of the bones forming the joints, being denuded by chronic wasting of 
the cartilages, and rendered smooth by attrition upon each other, are 
found to be white, glistening, and ivory -like in appearance. 1 The latter 
condition, we conclude, is that observed in what is termed "dry chronic 
arthritis" — Arthrite chronique seche of the French writers. We have 
had the opportunity of witnessing this alteration in several instances ; the 
state is that known as eburnation. In specimens which we have seen, the 
change of texture was chiefly marked in the track of the greatest attrition, 
in the affected joint ; a fact noticed particularly by Dr. Garrod. {Op. cit.) 

" The denuded surfaces become partly worn away, and a smooth enamel is 
formed by the mutual action of the bones on each other, and around the arti- 
cular surfaces thus acted upon bony vegetations arise. 

"In most joints, after the fluid has become absorbed, a crepitus is felt on 
movement from the rough surfaces grating against each other." (p. 540.) 

There is, in certain instances, a pulverulent deposit, usually consisting of 
lithate of soda, but containing also, at times, lithate of potash, ammonia 



1 Fuller. 



108 



M or land, Uraemia. 



[July 



and lime, chloride of sodium, phosphate and carbonate of lime. This 
lightly incrusts either the entire surfaces of the affected joints, or only 
portions thereof ; and it may pervade their solid structures. 

Although this deposit is identical, or nearly so, with that of gout, and 
Occurs alone in those cases of rheumatic gout most nearly resembling 
genuine gout, yet, says Dr. Fuller, " I cannot therefore admit the conclu- 
sion that the existence of such deposit is of itself sufficient to mark such 
cases as examples of true gout." (p. 331.) The reasons he assigus for 
this opinion are, briefly : 1. The occurrence of these cases in "thin, spare 
persons of temperate habits," who have had rheumatic rather than gouty 
symptoms ; 2. The difference in form and situation from the chalk-stone 
deposit of true gout ; 3. The disease occurs, often, in those who formerly 
have had pure uncombined rheumatism ; and these persons sometimes 
exhibit the well-known external traces of that disease. This author dis- 
tinctly avows his belief that rheumatic gout is a true combination of the 
two diseases whence it derives its name ; and when, on dissection, one joint 
is found to present most evidence of the gouty, and another most of a 
rheumatic element having been at work, he explains this by supposing 
that more of one influence was in force during the time such a joint was 
affected ; and the other result rests upon similar action from the opposite 
influence. Dr. Garrod, who, as we have already stated, does not consider 
the affection to be a compound of gout and rheumatism, admits, notwith- 
standing, its greater resemblance to rheumatism than to gout ; but he believes 
that much harm has been done practically, by confounding it with either 
gout or rheumatism. 1 

Such, then, are the principal results — if we adopt the theory received, as 
we have seen, by so many reliable observers, viz., that rheumatism depends 
on retention of uric acid in the blood — of this poisoning of the blood by 
the undue presence of the materies morbi in the system ; and both in this 
and the previously considered affection (gout) we have a series of symptoms 
indicative of the great extent to which the infection of the blood sometimes 
attains ; and also ocular evidence, both during life and after death, of the 
power and virulence of the poison. 3 

We have not treated of the occurrence of metastasis of rheumatism 
under a separate head, because the chief danger in this light is of the heart 
being affected, and we have already pointed out the frequency of such 
attacks, and the necroscopic phenomena. Sufficient allusion, we believe, 
has also been made to the occasional transfer of the affection to other 
organs. The sequelae of the disease have likewise been incidentally men- 
tioned under the head of results and consequent diseases. It is, however, 
not supererogatory again to refer pointedly to the extreme danger which 

1 We take this opportunity to refer those interested in these subjects, to the 
elaborate and interesting treatise of Dr. Garrod, which we have designated above. 
The differential diagnosis of gout and rheumatism is clearly set forth, and the 
work is fully illustrated by tables, plates, etc. 

2 It should be stated that the testes, as well as the skin, periosteum and aponeu- 
roses are occasionally affected, either concomitantly and acutely, or subsequently 
and in a more chronic manner. Dr. Fuller and others have enlarged upon the 
predilection of rheumatism for "the white fibrous tissue." The former author 
refers to the mention by Dr. Watson, of rheumatism of the articulation of the 
jaw, and also of that of the membranes of the spinal cord by Dr. Copland and 
others. (Op. cil., p. 46.) We need hardly refer to the fact of the frequent asso- 
ciation of rheumatismal attacks — in predisposed subjects— with gonorrhoea. 



1861.] 



Mo eland, Uraemia. 



109 



environs those who, during rheumatic fever, have also had heart disease. 
Such persons, even if apparently entirely recovered, are never to be con- 
sidered out of danger, and they require, of course, due warning from their 
physicians, and the exercise of great discretion on their own part, in order 
that they may be fully aware of their insecurity, and able, so far as is 
possible, to guard against a return or re-awakening of their formidable 
malady. 

We have thus endeavoured to present the chief phenomena, resulting 
directly and also secondarily from retention of uric acid in the blood. 
Whilst the manifestations of gout and rheumatism have been, of necessity, 
prominent, the reader will not have failed to remark the lengthy list of an- 
tecedent, concomitant, and subsequent, ailments, seemingly more or less 
dependent upon that morbid influence which, by common consent, is 
allowed to be the active promoter, and, we may say, the originator of the 
disease. From the slighter derangements of the general health, through 
all the phases of dyspeptical disorder, to the agonizing paroxysms of gout 
and rheumatism, their sequelae, exceedingly dangerous metastases and 
disastrous ravages upon the external form, both as to appearance and 
freedom of motion ; and finally in the post-mortem evidences of its activity, 
do we not seem to recognize the presence and morbid power of that 
"element of the urinary secretion" we have been considering, prevented as 
it is in such cases from obtaining an exit through its natural excretory 
channels ? 

Creatine and Creatinine. — Formulae: Creatine, C 8 H 9 N 3 4 4-2 Aq. 
— Creatinine, C 8 H 7 K0 2 . — 1 

Creatine. — This substance, discovered by Chevreul, in 1835, is crystal- 
lizable, and is derived from the juice of flesh. It is stated to be " present 

1 Thudichum. 

Chemical Composition of Creatine and Creatinine. 

Creatine: 8 equivalents of carbon . . .48 

3 " " nitrogen ... .42 
9 " " hydrogen . . . . 9 

4 " " oxygen . . .32 

Atomic weight of dry creatine 131 
To procure the formula for " crystallized creatine," 

Take, 1 atom of dry creatine . . .131 
and 2 atoms of water . . . .18 



149 

C 8 ,N 3 ,H 9 ,0 4 ,4-2HO=1314-18=149. 
C 8 ,H n ,N 3 ,0 6 . 

Creatinine: 8 equivalents of carbon . ... 48 

7 " " hydrogen . . . . 7 

3 " " nitrogen . . .42 

2 " " oxygen . . .16 

Atomic weight of creatinine 113 

C 8 ,N 3 ,H 7 ,0 2 ,=113. 

The formula expresses "crystallized" creatinine. 



36.64 
32.06 
6.87 
24.43 



100.00 



87.92 
12.08 



100.00 
Thudichum. 

G. Bird. 
G. Johnson. 

42.48 
6.19 
37.17 
14.16 



100.00 
Thudichum. 

G. Bird. 
G. Johnson. 



110 



Morland, Uraemia. 



[July 



in the blood and urine of man and of all animals hitherto examined." 
(Thudichum, op. cit.) Both this substance and creatinine, in the form of 
chloride-of-zinc salt, were found in the urine by Heintz and Pettenkofer, 
simultaneously, in 1844 ; but these chemists did not then recognize their 
identity with the above-mentioned product of the juice of flesh. Liebig, 
in 1847, demonstrated both creatine and creatinine to be " constant ingredi- 
ents of the juices of the flesh of nearly all the classes of vertebrate animals, 
and of the urine of man." {Idem.) 

Although now a recognized element of the urine, creatine is contained 
therein in an exceedingly minute proportion. It is always present in the 
blood, which is a fact important to note in respect to our present inquiry ; 
for, if naturally existing in the vital fluid as a product of a chemical 
muscular change or waste, it is doubtless innocuous so long as it is finally 
discharged by the kidneys, its proper emunctories. 1 And unless we suppose 
extensive renal disease and destruction of tissue or serious obstruction to 
the excretion of urine, it is not possible that undue accumulation of this 
substance in the blood should take place. Authors tell us that' it is to be 
considered as undoubtedly excrementitious (Golding Bird, Thudichum) ; 
therefore the blood must be depurated from it as it is formed and thrown 
in upon the circulation, or doubtless the phenomena of systemic disturb- 
ance, such as would arise from contaminated blood, would occur. And 
with this view, we should expect to observe somewhat analogous morbid 
phenomena to those produced by ursemic poisoning — bearing in mind the 
close relation to urea which is held by creatine, as has already been men- 
tioned, on the authority of Dr. Thudichum. 2 This supposition, which 
naturally occurred to us in view of the excrementitious nature of the 
substance in question, seems to find confirmation in the following remarks 
of the last-named eminent observer. " In disease, the quantity of creatine, 
together with that of creatinine, might serve to indicate the intensity of 
any spasmodic or convulsive action. The question as to its quantity in 
tetanic and epileptic disease is one of high interest. Cases of paralysis 

1 " Creatine is present in the blood, by which it makes its way to the kidneys. 
It occurs in the urine as a regular ingredient, though present in small quantities 
only. It is partly transformed into creatinine, most probably somewhere between 
the muscle and the urinary residue out of which the zinc salt crystallizes. For 
in the muscle, creatine has by far the preponderance over creatinine ; in the urine, 
creatinine over creatine. Creatine is, therefore, truly excrementitious ; its rela- 
tion to urea proves this beyond doubt. Its exclusive occurrence in the muscles 
shows the seat of its formation ; it is, with other matters, a product of the chemi- 
cal changes in the muscles." (Thudichum, op. cit., p. 120.)' 

2 In a ursernic case, Hoppe extracted five times the normal amount of creatine 
from the muscles of the patient. (Braun, op. cit., p. 99.) 

Dr. Golding Bird {Urinary Deposits, 1857) has some interesting remarks in 
reference to the modes of excretion of creatine and creatinine, and also in regard 
to their relation to urea. " Although we have seen that creatine and creatinine 
are both found in the urine, we must not conclude that they are entirely excreted 
in this manner. It is very probable that a considerable proportion of creatine is 
resolved into uric acid or urea before its final elimination. We have already seen 
the chemical relation of creatine to uric acid, and to urea ; its metamorphosis 
into the latter body, and into the peculiar substance sarcosin (which requires 
only the addition of the constituents of water to represent the elements of lactate 
of ammonia) is so readily effected, that a similar change occurring in the body 
is rendered very probable." (p. 109, English edition.) We may thus observe 
that it is very possible for a large amount of creatine and creatinine to be thrown 
out of the system in other ways than by the kidneys — a fortunate circumstance 
in renal disease, both when these and other urinary elements are concerned. 



1861.] 



Morland, Uraemia. 



Ill 



agitans, in which the spasmodic action ceases with sleep, may perhaps 
afford good opportunities for demonstrating the influence of rest and 
motion ; though the different nutrition in the muscle may, perhaps, vary 
the chemical changes in some degree. These suggestions for future 
researches must not be taken for theories or suppositions." {Op. cit.) 
There are almost no data, so far as we are aware, which could enable us 
to set forth, with any precision, the effects of an undue accumulation of 
either creatine or creatinine, considered as urinary elements, in the blood. 
As the author last quoted intimates, "future researches" can alone enable 
observers to furnish satisfactory details ; and although he is careful to re- 
pudiate the idea of issuing theories or suppositions, there seems no great 
presumption in hazarding the latter, as we have done in a former para- 
graph ; especially in view of a dearth of facts which precludes our offering 
much upon the subject. 

It is evident, however, that one practical deduction may be drawn from 
the fact that these substances are the result of muscular waste, viz., that if 
there is an excessive amount of them observed in the urine for a long time, 
this waste will also become extreme — consequently, rest and the appro- 
priate treatment for preventing debilitating action should be observed. 1 

Creatinine. — This "substance is found in the muscles of the vertebrate 
animals, and in the urine of man in larger quantities than in the muscles. 
It is the product of the natural or artificial decomposition of creatine 
* * *.» (Thudichum.) Its component elements are carbon, hydrogen, 
nitrogen, and oxygen. 

We have nothiDg further to present relatively to creatinine than what 
has already been incorporated under the head of creatine. 

Hippuric Acm— (Symbol : H. Formula : C 18 H 8 N0 5 +HO.) 3 
Liebig has announced this acid to be a constant ingredient of human 
urine ; a statement which, according to Thudichum, has lately been nega- 
tived by Duchek. It is stated that its existence was demonstrated in the 
urine of young infants by Scheele, Eourcroy, and Reynard. Benzoic acid, 
when ingested, becomes hippuric acid in the body. (Ure, Med.-Chir. 
Transact., vol. xxiv. ; and Keller, Ann. d. Ghem. und Fharm., xliii. p. 198 ; 
Thudichum, op. cit.) 

The pathology of hippuric acid is fully as undetermined as that of the 
two substances we have last considered. Its occurrence in the system in 
excess has generally been attributed and easily referable, to peculiarities 
in the diet. According to Dr. Golding Bird and some others, it seems to 
be found especially in those who live exclusively upon vegetables, milk, and 
certain kinds of fruit, and to be most constantly observed in persons of 

1 See, among other references on this point, Dr. HassaH's work on " The Urine in 
Health and Disease." 

2 Or, C 1S H 9 N0 6 . — Thudichum. 

Chemical Composition of Hippuric Acid. 



Carbon . . . 60.335 

Hydrogen . . . 4.469 

Nitrogen ......... 7.821 

Oxygen . 22.347 

Water 5.028 



100.000 

Thudichum. 



112 



Mob, land, Uraemia. 



indolent habits. This is esteemed the reason why it is detected in stall- 
fed cattle, or in well-fed stallions, and not noticed, but replaced by benzoic 
acid, in cattle that are worked or driven. (Thudichum et ah) Dr. Bird 
ascribes its presence in the urine of nursing infants — a fact already referred 
to — to their " mal-assimilating the large quantity of carbon contained in 
the food." This author, moreover, does not consider that it interferes 
with the production of uric acid ; but he observes that in hippuric urine 
there is generally a deficiency of urea. Reference is also made by him to 
very interesting cases by Boucharclat, Garrod, and Pettenkofer. In Bou- 
chardat's case, the acid was observed to coexist with albumen in the urine, 1 
and an absence of uric acid. The patient had lived for nine years on a 
milk diet, was fifty-three years old when the case was noted, had resided in 
the country, had good general health, was in easy circumstances, was the 
mother of one child, and had ceased to menstruate at the age of forty-five. 
Gastric and hepatic difficulties of an obscure nature led to her adoption of 
the milk-diet, and her health was restored. She then partook of a more 
mixed diet, eating some meat and vegetables ; after a time she again 
became ill, and the chief symptoms were lassitude, dryness of the skin 
(perspiration having previously been profuse) ; vague pains in the hepatic 
region ; jaundiced hue ; the feces were black ; the mouth dry, with a bad 
taste ; there were headache and tinnitus aurium ; imperfect vision ; palpi- 
tation of the heart ; excited pulse ; anaemic murmur in the carotids ; some 
oedema of the lower limbs ; dyspnoea. The chief phenomena, however, 
were excessive thirst and increase in the quantity of the urine. She often 
drank from six to ten pints of water in a day. The patient died ex- 
hausted. 

Dr. Garrod' s case was observed in the person of a young man, twenty- 
three years of age. The first signs of constitutional disturbance were 
"general malaise," with an excretion of an excess of urea from the kidneys, 
accompanied by a deposit of the ammoniaco-magnesian phosphate. Atonic 
dyspepsia, with lumbar pain, succeeded. At this time, hippuric acid, in 
"long crystals," was detected, and these were slowly incrusted with uric 
acid. This lasted for several days, and a pint of urine yielded about 40 
grains of hippuric acid. Uric acid and urea were observed in normal 
proportions. The hippuric acid soon decreased, and the urine finally 
became normal. "No information as to the source of the hippuric acid 
could be obtained from the history of the patient. He had lived on a 
mixed diet, and never used any excess of vegetable food, nor had he ever 
taken any benzoic acid." (Op. cit, p. 211.) 

The case reported by Dr. Pettenkofer is regarded by Dr. Bird as perhaps 
the most interesting of the three. The patient was a girl thirteen years 
old, affected with chorea, and long subject to it, under the care of Dr. De 
Marcus, of the Julius Hospital, Wurzburg. There had also been " anoma- 
lous hysteric symptoms." She had for a long time lived on apples, bread, 
and water, refusing any other food. The urine was yellow, limpid, and 
faintly acid when first excreted ; it soon became alkaline, and deposited 
crystals of the triple phosphate of magnesia. Adding hydrochloric acid to 
it, after moderate concentration there was "a copious formation of crystals 
of hippuric acid. The addition of nitric acid, by its oxidizing influence, 

1 Dr. Prout remarks that both xanthic oxide and hippuric acid "are undoubt- 
edly of albuminous origin." {Op. cit., p. 238.) 



1861.] Morland, Uraemia. 113 

caused the deposit of hippuric to be replaced by one of benzoic acid. In 
1000 parts of urine there were — of 

"Water 959.332 

Solids 40.668 



1000. 

Solids soluble in alcohol 18.451 

" insoluble in alcohol 9.417 

Anhydrous hippuric acid 12.800 



40.668 

Fixed salts, containing much carbonate of soda, 19,599. 

"The characters of the urine in this case approached those of an her- 
bivorous animal, in the presence of hippuric acid and of carbonate of soda 
in the ash, as well as in the absence of uric acid. 

" The hippuric acid disappeared, and the urine assumed its normal 
proportions on inducing the girl to return to a mixed diet." (Op. ext., 
pp. 211, 212.) 

We have given the substance of these cases, because they seem to bear 
so directly upon the portion of our subject now under examination. If, 
as may reasonably be inferred, the morbid phenomena, both the early and 
the later, may be ascribed to that state of the system which at last declared 
itself by the discovery of an excess of hippuric acid in the urine, we may 
logically argue that this was the morbific agent ; and that the surcharging 
of the blood with it, and the contamination of the various organs by this 
vitiated current, is the most plausible explanation. At all events, there 
seems to have been a direct connection between the morbid condition and 
the excess of the acid in the system. Dr. Bird and others, as has been 
mentioned, ascribe its presence in the urine in great excess, to the use of a 
not sufficiently nitrogenized diet, or to mal-assimilation of the carbon of 
the food. It has been presumed possible that, through the kidneys, hippuric 
acid vicariously depurates the liver from any excess of carbon. (Bird.) 
Supposing this to be true, and renal disease to supervene under these 
circumstances, the most disastrous results would seem to be unavoidable. 

There is no symptom or set of symptoms, so far as we are aware, 
which would indubitably indicate an excess of hippuric acid in the blood ; 
and the manifestations which we have enumerated, occurring as directly 
antecedent phenomena to the detection of such an excess, and seemingly 
dependent upon it, are only to be taken as probably the explanation thereof. 
It is, at least, reasonable to conclude, as we previously remarked, that when 
the acid appears, more or less suddenly, in excess in the urine, it has been 
equally so in the blood, and for a longer or shorter time — the period, 
possibly, being indicated more or less distinctly by certain morbid signs. 
Dr. Golding Bird closes his remarks upon the Pathology of Hippuric Acid 
in the following terms : "My own experience in these cases has been too 
limited to justify my offering any opinion on the pathological complications 
attending them. From what little I have observed, I feel inclined to believe 
that when an excess of hippuric acid exists, it may always be regarded as 
traceable to, or pathognomonic of, the deficient function of the liver, lungs, 
or skin, the great emunctories of carbon ; or to the use of food deficient in 
nitrogen. It hence follows, that our treatment will consist in appealing 
to the function at fault, and carefully regulating the diet. 
No. LXXXIIL— July 1861. 8 



114 



Morland, Uraemia. 



[July 



"I would suggest the propriety of seeking for the presence of hippuric 
acid in the urine, where it is copious, of low specific gravity, but slightly 
acid or neutral, and occurring in persons who have a dry and inactive state 
of surface, with anaemia. In many pseudo-chlorotic cases in both sexes, I 
am inclined to believe an abnormal proportion of this acid will often be 
met with." (Op. cit, p. 213.) 

Dr. Thudichum refers to the discovery, by Lehmann, of hippuric acid in 
diabetic urine, whenever he had sought for it ; and also in the acid urine 
of fever-patients, "of which it is said to cause, in part at least, the acid 
reaction." Hiinefeld and Duchek confirmed the experiments of Lehmann. 
Schlossberger found hippuric acid in the scales of ichthyosis. Whether this 
was only an isolated instance, "or whether it is of frequent or constant 
occurrence in that disease," is not stated. (Auct. ante cit.) 

Many observations are needed before we can attain to any more precise 
knowledge of the pathology of hippuric acid. The subject is yet in that 
undeveloped state which induced Dr. Thudichum to conclude his chapter 
upon it in these words : " The reader will think this a very unsatisfactory 
chapter, and so indeed it is. We want observations, for which there is a 
large field open. But undoubtedly some technical difficulties will have to 
be overcome first, before the analysis of hippuric acid can be made with 
sufficient accuracy." (Op. cit., p. 152.) This author has recently investi- 
gated the subject in its chemical, physiological, and pathological relations ; 
and if he finds the stores of information in regard to it so meagre, and if 
Dr. Prout was obliged to confess that he was not aware that hippuric acid, 
either in excess or in deficiency, is characteristic of any peculiar disease 
(op. cit,, p. 239), we surely need not shrink from avowing the poverty of 
our own knowledge in the matter. 

Chlorine: Chloride of Sodium. 1 

Were we to follow Dr. Golding Bird's estimate of the "essential" 
elements of the urinary secretion, we might now pause in our examination 
of the list of ingredients which we at first enumerated as entering into its 
composition. Dr. Bird, after mentioning what he terms the "Organic 
Products," viz., urea, uric acid, creatine, creatinine, colouring and odorous 
principles, together with hippuric acid and lactic acid, which latter he also 
styles "accidental constituents," says that this "class of ingredients can 
alone be considered as really essential to the urine, and characteristic of it 
as a secretion, the kidneys being the only organs which normally eliminate 
these elements from the blood." The saline ingredients, as he remarks, 
"are met with in most secretions of the body, with the exception of the 
sulphates, which are rarely found except in the urine." The "ingredients 
derived from the urinary passages" (Dr. Bird's Third Class) are found 
"in all fluids passing over mucous surfaces, the phosphate of lime being 
derived from the mucus, of which it is a constituent." 

Since, however, there are many interesting and important points con- 
nected with the consideration of the remaining constituents of the urine as 
given by Dr. Thudichum, whose table we have adopted in preparing this 
essay, we will bring them separately under consideration according to our 
original plan. What we have to present, however, will naturally be more 

1 Chemical Composition of Chloride of Sodium : — 

Formula : NaCI. 1 Q^tarine' ' ' 35 5 } 58 * 8==1 equiv. chloride of sodium. 



1861.] 



Morland, Uraemia. 



115 



general, since we have no affections to consider in this relation, which like 
gout and rheumatism seem to depend so entirely upon some morbific matter 
retained in the blood. That an excess or diminution of the chlorides and 
of other matters in the system, has a greater or less bearing and significance 
in certain diseases, seems to be proved in many instances, and in others 
rendered extremely probable. It will be our object in the remainder of 
this essay to illustrate these positions so far as we may be able ; bearing in 
mind that our main purpose is to indicate the results determined by the 
undue presence of these elementary substances in the circulation. 

With regard to the mere presence of chloride of sodium — which sub- 
stance we shall make the foundation of our remarks — in the blood, it is 
well known that there is always a greater or less amount taken into the 
system with the food. There is, indeed, a strong natural appetite for salt, 
both in men and animals; which, however, varies remarkably in different 
individuals. From the fact of the almost universal desire for it which 
exists, we cannot suppose that it is, per se, ever noxious, unless it be 
ingested in enormous and unnatural quantities ; or unless, through other 
influences, the proper balance of its proportions in the blood be perma- 
nently or for a long time disturbed. 

The valuable experiments of Barral, 1 Regnault, and Keiset, alluded to by 
Dr. Bird, Dr. Thudichum, and others, led to the conclusion that the elimi- 
nation of the nitrogenized elements of the urine was facilitated by the 
action of the chloride of sodium. Dr. Thudichum thinks that if equally 
careful experiments were again conducted "by the more accurate methods" 
now at our command, we should acquire very important information in 
respect to the " causes and influences" which determine and modify the 
amount of chlorine thrown off by the kidneys ; and this especially if the 
feces and other excreta were taken into the calculation. Barral ascertained 
by his experiments, both the whole quantity of chlorine taken with the 
food, and also that of chlorine and urea excreted. The action of chloride 
of sodium is certainly salutary also in another way ; and which is particu- 
larly pointed out by Dr. Thudichum, viz., by its causing thirst, and con- 
sequently inducing the ingestion of an increased quantity of water, the 
diuretic influence of which, by producing a more copious urinary flow, 
"carries away not only the salt, but also organic ingredients in solution." 
(Op. cit., p. 165.) 

The Relation of Chlorine to Pneumonia and other Acute Diseases. — 
The very striking fact of the rapid diminution, and occasional temporary 
disappearance of the chlorides in the urine of pneumonic patients — first 
pointed out by Simon and Bedtenbaoher, and subsequently sedulously 
tested by several observers, amongst whom Dr. J. H. Bennett may be 
named as having supplied us with a large amount of clinical observation — 
naturally arrested the attention of pathological chemists and medical prac- 
titioners. It was at first supposed that the above-mentioned diminution 
was distinctive of the pneumonic inflammation ; but subsequent researches 
seem to preclude this idea. Dr. Thudichum has lately announced the fol- 
lowing proposition relative to this point : " The result of many observa- 
tions of Yogel and others, last, of myself, then, is that in all acute febrile 
diseases the amount of chlorine discharged in the urine sinks rapidly 
to a minimum, say one hundredth part of the quantity normal to the in- 

1 Barral, S. A., " Siatique chimique des Animaux, appliquie specialernent d, la 
question du se/," Paris, 1850. (Thudichum.) 



116 



Morland, Uraemia. 



[July 



dividual, until at last, in certain cases, it disappears entirely for a short 
time. When the diseased action is abating, the amount of the chlorides 
rises during convalescence, sometimes above the normal average." {Op. 
cit, pp. 165-6.) 

While, therefore, this diminution in and temporary disappearance of the 
chlorine is not found to be solely characteristic of pneumonia, the cases of 
that disease in which it has been observed afford very striking illustrations 
of the fact. For detailed accounts of these, the recent work of Dr. Bennett, 
already referred to, may be consulted with great advantage. Dr. Beale, of 
London, has also given us much reliable information upon this important 
topic. (See Medico- Ghirurgical Transactions, vol. xxxv.) The rule in 
pneumonia seems to be that the diminution of the chlorides indicates the 
progressive stage of the disease ; at its height, the chlorides may wholly 
disappear; their reappearance is a sign of improvement, with cessation of the 
inflammatory action, and occurrence of the crepitus redux. Dr. Bennett 
thinks it established that, although absence of the chlorides may be found 
to exist in some other diseases, and may thus lessen the value of the sign 
in pneumonia, it yet leaves it unaffected in importance, " as pointing out 
the onward progress of that disease." {Op. cit, p. 640.) The appearance 
of the chloride of sodium — thus excluded from the urine of pneumonic pa- 
tients — in the sputa, and its desertion of the sputa when it again becomes 
manifest in the urine, is another remarkable fact connected with these ob- 
servations. Experiments conducted by Mr. Seymour, Clinical Clerk, upon 
more than sixty pneumonic patients in Dr. Bennett's wards, established the 
fact that the chlorides were absent in all but one ; and that was a case of 
phthisis, with intercurrent pneumonia. 

The question to which we now recur, is virtually that at the foundation 
of our present researches, viz., does any morbid action result from the re- 
tention of the chlorides in the blood? Irrespective of what we have already 
said of the avidity with which the chloride of sodium is sought by man and 
animals, and its innocent nature unless inordinately ingested — when, indeed, 
it would in all probability be either vomited or discharged from the bowels 
. — we learn from chemical and medical authority that the blood always re- 
tains a portion of the chlorides. The fact of the chlorides beiug found in 
large quantity in pneumonic sputa, is explained on this ground by Dr. 
Thudichum, viz., that sputa being, in part at least, " extravasations and 
exudations from the blood," the chlorides would naturally appear in a sub- 
stance partly composed of exuded and " stagnant" blood. It does not seem, 
then, from all that we can discover is as yet known, and considered as 
material from which to draw conclusions, that pneumonia, or the other 
diseases in which the absence of the chlorides from the urine is remarked 
as a feature, can be distinctly ascribed to that fact as a prime cause. Were 
this to be predicated of any one affection, however, it would certainly be of 
pneumonia. An extensive field is open for important and interesting ob- 
servations in the direction of the present inquiry ; but should it be here- 
after ascertained that the amounts of chlorine absent from the urine, and 
therefore presumed to be circulating in the blood, are to be considered as 
more or less poisonous, either by their quantity or quality, we still must 
remember, in estimating such an action, that there are other channels of 
excretion open, by which [a portion of the chlorine is excreted. The con- 
stant occurrence of diminution or abolition of the chlorides in pneumonia, 
is a curious and important fact ; but, as yet, not sufficiently illustrated by 
observations and study, to take the place of an etiological element of dis- 



1861.] 



Morland, TTrcemia. 



117 



ease. Dr. Thudichum states, in respect to the questions under considera- 
tion, " the absence of the chlorides in the urine does not necessarily involve 
the absence of chlorine from exudations. For the latter are products of 
diseased action derived directly from stagnant blood, and certainly uot sub- 
ject to the specific laws of secretion. The presence of chlorine in sputa, 
therefore, at a time when it is absent from the urine, is not sufficient proof 
of a determination of the chloride towards the inflamed lung ; a proposi- 
tion which, moreover, loses all probability from the partial or total dis- 
appearance from the urine of the chloride in all acute diseases." (Op. cit, 
p. ]66.) He then enumerates bronchitis, typhus, acute rheumatism, pyae- 
mia, and pleuritis, as examples of this fact ; and also refers to the influence 
exerted in the system by varying quantities of chlorine introduced into it 
with the food, ascribing no inconsiderable amount of this effect to the sort 
of diet used by the patient when the quantity of chlorine in " pathological 
urine" is to be estimated. In most acute diseases, it is known that patients 
take but little food — often none — and that the articles they eat are often 
unsalted. Another fact of consequence, which is insisted on by Dr. Thudi- 
chum, is, "that urine containing no appreciable trace of chlorine is secreted 
from blood containing a certain amount of it ; from which it follows that 
the composition of the blood is such as not to allow any further removal 
of chlorine, or that the kidneys have lost their secretory activity as regards 
chlorine, as well as (which has been seen to be the case) with reference to 
water." (p. 167.) 

As has been shown to be the fact with regard to pneumonia, so it may, 
in the opinion of the latter writer and others (and it is no less deducible 
analogically), be considered available to esteem the amount of chlorine in 
the urine, a gauge of the amount of morbid action going on in the system 
in certain other affections. That is, an estimate, more or less accurate, 
may be made as to the severity and activity of the disease. The minimum 
of chlorine in the urine, in making such estimates, Dr. Thudichum places 
at 0.5 gramme; and after that, in the intensity of the disorder it may, as 
we have seen, be altogether wanting. " This may be the combined effect 
of an entire loss of appetite, copious serous diarrhoea, or other serous exu- 
dations ; of secretions, such as perspirations ; and of the want of secreting 
power of the kidneys. A rise in the amount of chlorine, on the other 
hand, indicates a steady abatement of the acuteness of the disease, and is a 
good measure of the returning appetite and improved digestive powers of 
the patient." 

We referred, previously, to the experiments of Barral and others, which 
seemed to show increased activity of nitrogenous elimination through the 
agency of chloride of sodium. Dr. Golding Bird remarks, in this connec- 
tion, that it would seem that this chloride, "besides furnishing hydrochloric 
acid to the stomach, and soda to the bile, also exerts an important physio- 
logical influence in aiding the metamorphosis of tissue, and consequent 
depuration of the blood." (Op. cit., p. 127.) If we accept this as true, 
we not only need not ascribe any morbid effects to the retention of chlorine 
— or of chloride of sodium — in the blood, but rather deem its presence 
desirable and salutary — at all events, in the vast majority of cases. 

Certain of Hegar's conclusions, which were arrived at under the super- 
intendence of Liebig and Yogel (G. Bird), are interesting in this connec- 
tion. We select a few, in illustration : — 

" The amount [of chlorine in the urine] varied in different individuals, 
depending partly on the food, and partly on habit of life and constitution." 



118 



Morland, Uraemia. 



[July 



"It was increased by exercise and copious draughts of water, which appeared 
to act by washing it out of the system, as the augmentation was only tem- 
porary." " Indisposition diminished the quantity." " In health, though no 
chlorides were taken with the food, they were always found, and must therefore 
have been obtained from the blood or tissues." " When a larger quantity was 
taken than usual, the whole did not escape from the system by the kidneys, nor 
even the bowels." 

The latter two facts would seem to go far to prove the innocuousness of 
even considerable amounts of chlorine in the blood. Dr. Day (Contribu- 
tions to Urology) is quoted by Dr. Bird as testifying to the fact to which 
we have previously called attention ; that the chlorides are diminished in 
all cases of disease accompanied by copious exudation from the blood. 

We notice that Dr. Bird asserts, as from Dr. Beale, that the nature of 
the diet necessarily adopted in pneumonia and other acute diseases, seems 
insufficient to explain the absence of the chlorides from the urine. Doubt- 
less this default of ingestion of chlorine will not fully meet the require- 
ments of the case in the way of explanation, but it seems only reasonable 
to allow it no inconsiderable weight. The following are Dr. Beale's very 
important propositions : — 

"1. That chloride of sodium is totally absent from the urine of pneumonic 
patients at the period of complete hepatization of the lung. 

" 2. The chloride reappears after the resolution of the inflammation. 

" 3. The chloride exists in the blood in the largest quantity, when most 
abundant in the urine, and vice versa. [We may here, again, find reason for 
inferring the harmlessness of even large quantities of chloride of sodium in the 
blood ; for when it is considered that under these circumstances, were it easily, 
or at all, a cause of disease, the conditions for the development of morbid 
action abundantly exist, we certainly have sufficient ground for the above 
opinion.] 

"4. The chloride exists in very large quantity in the sputa of pneumonic 
patients. 

" 5. There is reason to believe that in pneumonia the chloride is determined 
towards the inflamed lung, and is re-absorbed and removed on the resolution of 
the inflammation." 

The validity of this latter proposition, as we have previously stated, is 
denied by Dr. Thudichum ; and if it is meant thereby, as it would seem to 
imply, that the chloride of sodium is the morbific material, we cannot see 
any sufficient reason to suppose such a relation of cause and effect as by 
any means certain. That there is a degree of plausibility about it, we 
confess ; but not, at present, any satisfactory proof. 

In chronic diseases, the amount of chlorine excreted is usually diminished. 
This would tend to ratify the supposition that failure of the appetite, and 
the consequent less ingestion of food, explain the decrease in the chlorine 
introduced into the system ; and the fact consorts, also, with the enfeebled 
nutrition. Lecanu found the quantity of chloride of sodium very small in 
the urine of women and old men (Simon's Chemistry, vol. ii. p. 167. 
Sydenham Society's edition.) Observers point out diabetes insipidus as 
an exception to this rule ; the chlorine discharged being in excess. So, in 
dropsy, Vogel found the chlorine increased under artificial diuresis. Chlo- 
rine here becomes a gauge of the powers of digestion. It may be inferred 
that digestion is in good order, when from six to ten grammes are excreted 
in twenty-four hours ; any quantity below five grammes, for the same 
period, declares an impaired nutrition, unless the diminution can justly be 
ascribed to a diet very deficient in chlorine, or entirely without any. So 



1861.] 



Morland, Urasmia. 



119 



those discharges which diminish the amount of chlorine contained in the 
blood, "as serous diarrhoea, exudations and perspirations," should be taken 
into account in making an estirnate of the morbid action. When the 
amount of chlorine is very largely increased, and there has been no corres- 
ponding plentiful supply by ingestion, diabetes insipidus may be inferred. 
"In dropsical and hydremic conditions, an increase of the amount of 
chlorine is a favourable symptom." (Vogel, by Thudichum, op. cit., p. 
168.) 

If this portion of our subject seems to have been presented in a some- 
what negative manner, it is because the information attainable in reference 
to it is of the same nature. We seem able to say rather wherein the 
presence of chlorine in the blood — at all events of such amounts as are 
derivable from diverted excretion thereof by the kidneys — is harmless or 
even beneficial. Notwithstanding, it must be confessed, that observations 
and researches upon this point are not available in such quantity as to 
enable any one, at present, to set forth entirely reliable practical rules and 
conclusions. 

Sulphuric Acid. (Formula: SO3-I-HO 1 : Equivalent, 16.0 Sulphur; 
24.0 Oxygen=40,0, Sulphuric Acid.) ° 

A variable, and often very considerable amount of sulphuric acid is dis- 
charged from the body by the kidneys during each twenty-four hours. 
When it is considered that sulphur must nearly always exist in the blood, 
in greater or less amount — being derived from the food — it will be con- 
ceded that it is unlikely that any retention of it therein, even after its oxi- 
dation, unless it be present in very large and improbable quantities, would 
be influential in inducing actual disease. We will examine the known re- 
lations of sulphuric acid, as contained in the urine, to the system — so far 
as facts enable us to present anything worthy of credence and likely to prove 
of service. 

Liebig, referring to Wohler's experiments, ascribes the sulphuric acid 
generated in the system, to the action of the oxygen of the atmosphere 
upon the sulphur introduced into the blood through the medium of food — 
and this is particularly true of the albuminous portion thereof, which, of 
course, constitutes, as a general thing, a large amount of the whole. This 
process of oxidation, and consequent manufacture of sulphuric acid in the 
system, carried on as it is through the medium of the blood itself, seems to 
confirm our previously announced opinion, that this acid, in itself, is in- 
nocuous. If a very large amount were long and habitually retained in the 
circulation, it will be easy to understand that mischief might ensue. Before 
examining any possible or probable pathological issues, we will further al- 
lude to certain physiological facts connected with the existence of sulphuric 
acid in the system, and its excretion from it. It should be said, before 
proceeding further, that the oxidizing process above mentioned accounts 
for the surplus of sulphuric acid which is eliminated from the body, over 
and above what is ingested with the food, in the form of sulphates. (Lie- 
big, Simon, Thudichum.) It is therefore evident that a full animal diet 
will, by introducing more sulphur into the blood, increase the amount of 
sulphuric acid in the urine — and that, under the same conditions, more must, 
for a time at least, be contained in the blood. The experiments of Leh- 
mann on himself show conclusively the effect of different sorts of diet in 



1 " Being the hydrate of sulphuric acid." (Thudichum, op. cit.) 



120 



MorlanD, Uraemia. 



[July 



increasing or diminishing the quantity of sulphuric acid passed in the urine. 
Thus, while on a " mixed" diet, 7.026 grammes of the acid were collected 
during twenty-four hours ; when animal food was exclusively used, the 
quantity rose to 10.399 grammes in the same time ; when living on vege- 
tables exclusively, only 5.846 grammes were obtainable in the course of one 
day. Dr. Thudichum, commenting upon these quantities, pronounces them 
very high, and is inclined to attribute this to Lehm ami's appetite. He was, 
it is true, in fine health and of robust constitution, and therefore some 
allowance is to be made ; but, as Dr. Thudichum also implies, the intrinsic 
value of the experiments is unaltered by the mere amounts. The ratio of 
formation of the acid, under the differing influences, is the essential point. 
Certain very conclusive experiments by Yogel, Clare, and others upon this 
subject, are given in some detail in the work of Dr. Thudichum. The re- 
sults are the same in character as those obtained by Lehmann. 

There exists, as yet, no test or other means of revelation, so far as we 
are aware, which can inform us what amount of sulphuric acid may be re- 
quired by the system in its different states. We know the beneficial effects 
derived from its medicinal use as a tonic, refrigerant and astringent ; and 
thus it would appear that in certain states of the constitution it is especially 
suitable — we may, indeed, say indicated. Whether a certain amount of the 
sulphates must enter into the circulation in order to perfect secretion, " or 
whether sulphates may be retained and accumulated in the economy," is, at 
present, unknown. Dr. Thudichum, while stating this fact, mentions that 
neither rest, nor activity, nor the ingestion of large quantities of water, 
seemed materially to affect the amounts of sulphuric acid in the urine, in 
certain of the experiments of Clare and Gruner. Yogel, however, he states, 
believed " it probable that such influences exist, that the secretory activity 
for sulphuric acid is dependent upon certain individual and cosmic influ- 
ences" {pp. tit., p. 175) ; and this is rendered nearly certain by the fact of 
the difference in the rapidity of oxidation of the introduced sulphur ob- 
served in various persons. A very significant opinion of Yogel, quoted by 
Dr. Thudichum, is of importance as affording a valuable suggestion closely 
connected with our present inquiries, and in respect to which we need more 
extended observation. It will be seen, as we just remarked, that the sug- 
gestion bears directly upon the point which now engages our attention ; 
and all inquiries of this nature must tend greatly to advance our knowledge 
of any diseased conditions (and of the remedial measures suited to them) 
which may reasonably be supposed to depend, even remotely, upon an undue 
accumulation of the products we are considering, in the blood. The state- 
ment to which we have reference is as follows : — 

" Yogel, also, from observation, is of opinion that the prolonged use of sul- 
phates in digestive doses is decidedly weakening, and believes it probable that 
this depressing action may be due to an accumulation of the salts in the system. 
When to this it is added that sulphate of soda in larger doses is an emetic, and 
sulphate of potash a poison, the question as to the influence of sulphuric acid 
and sulphates in the urine becomes one of sufficient importance to fix the atten- 
tion of future inquirers." (Loc. cit., p. 176.) 

From the same sources of authority we learn that the amount of sul- 
phuric acid in the urine is diminished in febrile diseases. This, as is plau- 
sibly suggested, may, in great measure, be ascribable to the nature of the 
food taken, viz., mainly vegetable — less sulphur being thus supplied to the 
blood ; and it must also be remembered that the quantity of food is very 
greatly diminished under such disordered conditions. 



1861.] 



Morland, Uraemia. 



121 



Dr. H. Bence Jones (Medic o-Chirurgical Transactions, vol. xxxiv.) 
found the amount of the sulphates increased in chorea, and in aggravated 
cases of delirium tremens ; and he likewise notes a similar augmentation, 
both of the sulphates and phosphates, in cerebral inflammation. He ascribes 
this occurrence to the rapid disintegration of muscular tissue in the former 
affections, and to excessive and rapid oxidation of the cerebral substance in 
the latter. 

Yogel found, in three pneumonic patients, the amount of sulphuric acid 
discharged, exceptionally, "above the normal average." In chronic dis- 
eases, while the quantity was variable, it was generally below the standard 
amount. It was not increased under a diuretic action which largely aug- 
mented the discharge of the chlorides, as in cases of dropsy. The ingestion 
of sulphuric acid and sulphates by patients labouring under chronic disease, 
alone produced any increase in the amount excreted ; and a hearty meal 
of animal food had the same effect in patients suffering from diabetes. 

While we are obliged to speak doubtfully as to any abnormal effects as- 
cribable to the action of various amounts of sulphuric acid retained in the 
circulation, we can say — as we have already once stated — that such effects, 
from any increased amount likely to be thrown into the blood by failure of 
the renal excretory function devoted to separating this acid, are not such 
as to be defined, with our present knowledge ; nor can we believe any 
very serious results likely to follow under such circumstances. If all the 
urinary elements were retained, or only such as greatly predominate — and 
which we have previously considered — then the other accidents, already de- 
tailed, would very surely mask any minor morbid action ; and if either urea 
or uric acid predominated, we should have their peculiar concomitant or 
resulting phenomena, to the exclusion of any weaker manifestations. While, 
therefore, nothing positive can be charged to the presence of sulphuric acid 
in excess (more or less) in the system, we are fortunate in having sug- 
gestions from reliable sources, and accurate chemical observations from 
many competent hands. And all will join Dr. Thudichum in estimating 
very highly the determination of the quantity of this acid in the urine as 
being a sort of index of "the amount of disintegration of albuminous 
matters in the system, in cases where the ingestion of sulphur in any form 
or combination is very low or altogether suspended." He goes on, also, 
to remark that possibly a degree of correspondence of the acid with urea, 
in amount, might be found to exist, " supposing their inclination to pass 
the kidneys to be equally great. But upon this point there are yet doubts." 
(p. 17?.) If both sulphuric acid and urea be largely excreted, we are to 
infer that very free oxidation is going on in the system, and is due to the 
ingestion of animal food in abundance. The opposite condition with re- 
spect to sulphuric acid, would go to show a diminution in, or entire depri- 
vation of animal and vegetable food. These states may be either constant 
or accidental. (Thudichum.) We have already hinted that a sudden, 
temporary increase in the amount of sulphuric acid excreted, would seem 
to indicate a reception of sulphur, in some of its forms, into the system, 
and that too in large quantity. 

Dr. Thudichum thinks that new analyses of the blood will have to be 
made, and without incinerating it. This, he states, "destroys the relative 
proportions of acids and bases in the salts of the alkalies." We may thus 
hope not only for more accurate chemical information upon these points, 
but also that new and more abundant pathological inferences will be drawn 
from such researches. The fact that the production of sulphuric acid is 



122 



Morland, Ursemia. 



[July 



proved, to all appearance, to be restricted to the blood, and that it is 
formed through the agency of the oxygen of the air, by means of the 
respiratory function, is highly important in relation to the present portion 
of our subject. Its being formed, in great measure, in the blood, is favour- 
able to the idea we have before mentioned, viz., that the vital fluid will be 
more likely to tolerate its presence, even in large quantities. If this opin- 
ion should be deemed merely speculative, we can only say that most of the 
information now existing upon the subject is of the same nature. 

Another interesting question, founded upon the seeming fact that the 
sulphuric acid is in great part formed in the blood, from the aliments — and 
also referring to the remark by Liebig, "that the acid nature of the urine 
of carnivorous animals, as well as that of men, depends upon the nature of 
the bases partaken of in the aliments, and upon the particular form of their 
combination" 1 — is, how far the office of the kidneys is to finish the " final 
oxidation, or that stage of disintegration of albuminous matter in which 
sulphur, in the form of sulphuric acid, leaves the organic combination, joins 
a base, and appears in the urine." (Thudichum, op. cit, p. 118.) These, 
and other chemico-pathological inquiries, as has already been intimated, 
must be left to future investigators to determine. So far as our present 
means afford us any ground for the pathological inferences connected with 
this portion of our subject, we are compelled — after having presented what, 
for the greater part, is as yet conjectural and undetermined, although 
seemingly interspersed with the elements of truth, and certainly accompa- 
nied by many precise chemical facts — to rest the matter here. 

Phosphoric Acid.— (Formula : P0 5 +3HO.) 3 

This acid is the next regular constituent of the urine which we are to 
consider, pathologically. Previous to entering into any particulars, it may 
be said that its position in relation to pathological states of the system, 
generally, very closely resembles that of sulphuric acid. We shall there- 
fore treat of it in much the same manner as was adopted in examining the 
latter substance. 

Phosphorus enters the system constantly, and often in very considerable 
quantities. It is taken with the food, and it has also been long medicinally 
ordered. Within a short time, indeed, the phosphates and phosphites of 
lime and soda have been prescribed with variable results, as nervines, and 
also as being suited to combat the ravages of tuberculous disease of the 
lungs. In certain cases, we may add, they are reported to have been of 
service ; and we can recall cases of general prostration, and of what has 
been sometimes termed "nervous debility," in which we have used them 
with apparently marked benefit. To Dr. Churchill, now of Paris, belongs, 

1 Liebig, quoted in Simon's Chemistry, vol. ii. p. 153. (Lancet, 1844.) 

2 " The common or tribasic phosphoric acid." 

Chemical Composition of Phosphoric Acid. 

1 equivalent phosphorus P=31.436 

8 equivalents oxygen =64.000 

3 equivalents hydrogen = 3.000 

1 equivalent of phosphoric acid . . . . =98.436 
"The theory which assumes P to be a double atom, and the single atomic 
weight=15.718, uses P 2 as the symbol for the above equivalent of phosphorus. 
This is an explanation to the reader, should he find himself embarrassed by the 
formulae of different authors." — Thudichum. 



1861.] 



Morland, Uraemia. 



123 



we believe, the credit of suggesting their persevering employment in threat- 
ened, or actually existing, pulmonary consumption. The success attained, 
although flattering in many instances — as we learned, personally, not long 
since, in the French capital — has not, by any means, justified the expecta- 
tions at first excited. 

This seeming digression from the immediate course of our subject, is not, 
after all, an element actually foreign to its consideration; for we may thus 
at least be led to examine what cases will be likely to derive benefit from 
the ingestion of phosphorus into the system. 

The amount of phosphoric acid present, normally, in the urine, is con- 
siderably less, according to Becquerel and Rodier, Golding Bird, Johnson, 
Prout and others, than that of sulphuric acid ; and it is found in combina- 
tion with lime, ammonia, soda, or magnesia. Dr. Thudichum, we notice, 
in his estimate in the table from which we have taken our list of urinary 
constituents, has made the amount greater. In the system generally, the 
quantities existing at different times, will vary from nearly the same causes 
as have been assigned for the changes in the quantity of sulphuric acid ; 
viz., the nature and amount of the food taken, and the ingestion or other- 
wise, of phosphorus in a medicinal form. The same difference in rapidity 
of excretion of phosphoric acid, is observed in different persons, as is true 
with regard to sulphuric acid. And in respect to the activity and amount 
of excretion, the same variations are to be remarked as have been recorded 
for chlorine and sulphuric acid. Therefore, renal disease must be considered 
an important pathological influence in respect to the amounts excreted, as 
personal peculiarities and fortuitous circumstances as to diet, &c, are 
observed to be, physiologically. We learn from Yogel, that copious 
draughts of water will increase the amount of phosphoric acid excreted by 
the kidneys — a fact similar to what has been mentioned in respect to the 
chlorides. As Dr. Thudichum remarks, in commenting upon this point, 
and as we have previously intimated, " the organism may at one time con- 
tain an excess of phosphoric acid, at other times the acid maybe deficient." 
" It will, however," he adds, '"be difficult fully to establish these points, 
until the normal amount of phosphoric acid contained in all parts of the 
body, and its changes and variations, within the range of perfect health, be 
known. And then the examinations will have to comprise a complete 
analysis of all food, and of all excretions." (Op. cit., p. 188.) 

The decrease of phosphoric acid in acute disease, noticed by Yogel, is 
ascribed partially, as was the fact with regard to sulphuric acid, to the 
diminution and quality of the diet ordered or made necessary. When the 
rations are richer and more liberal, the phosphoric acid increases in quan- 
tity ; and in convalescence the normal amount is often exceeded, owing to 
the increased ingestion of food. The decrease of phosphoric acid bears a 
notable proportion to the period of time the illness lasts — even if the 
attack be violent, and much fever accompany. If short, there is little 
variation in the amount of acid excreted, and vice versa. Severity and 
prolongation of the disease, with great diminution of, or total abstinence 
from food, causes very marked decrease in the quantity of phosphoric acid 
appearing in the urine. In chronic diseases, no rule is observed. Some- 
times, and indeed usually, there is great diminution in the amount, and 
again there may be excess. 

Certain statistics supplied by Dr. Thudichum, relatively to the quantities 
of phosphoric acid excreted in various diseases, and at different stages of 



124 



Morland, Uraemia. 



[July 



each affection, have an important bearing upon the subject. In a table 
given by him (op. ciL, p. 191), the most remarkable points, perhaps, are 
that the largest amount mentioned (" maximum") as excreted, was in the 
case of a female with diabetes insipidus (7.8 grammes) ; the next largest, 
in a male, suffering from hydruria (5.8 grammes). This seemingly ratifies 
the remarks and observations previously made, that where the kidneys are 
most actively employed, the most phosphoric acid is excreted. 

If the question be now asked, whether there is any relation between the 
deficient excretion of the acid in question, and the diseases which have been 
specified as exhibiting less of the excreted product during their acute course 
— this implying the retention of a greater or less amount of the substance 
in the blood — we must admit that no positive proof of this absolute con- 
nection as yet exists. In this respect, as in many others pathologically 
important, the subject is very much in the position of the one last examined. 
We have already, incidentally, referred to the detection of an increased 
amount of the phosphates — in connection with the sulphates — in the urine 
of persons with cerebritis, by Dr. H. Bence Jones. This phenomenon, 
ascribed by that accomplished observer to rapid oxidation of the cerebral 
tissues, will, we conclude, hardly justify us in ascribing the inflammatory 
attack upon the brain, in any degree, to increase and undue retention of 
the phosphoric acid in the circulation. It does not appear, moreover, that 
the kidneys were at all disabled ; had they been, it is not impossible but 
more serious mischief might have occurred in such cases — although it is 
known that a portion of the phosphorus entering the system, goes off by 
the bowels, as well as from the kidneys. 

Earthy Phosphates. 1 

We have previously mentioned the medicinal use of the phosphates, with 
the purpose of adding to the nervous force, and in the hope of obviating 
tuberculous disease. The phosphates of lime and of soda have thus far 
been prominent in these respects. The latter is physiologically essential 



Chemical Composition of the Phosphates. 



Ammonio-phosphate of soda=P0 5 +NaO+NH 4 0-j-HO-f 8HO. J §3 
Acid " " " =P0 5 +NaO+2HO. j §>> 

Ammonio-phosphate of magnesia==P0 5 -f2MgO-f NH 4 0+12H0. { a 



Phosphate of lime (acid), =P0 5 4-2CaO-|- HO. J Pg^ 

Phosphate of magnesia, =P0 5 +2MgO-fHO. 1 | §; 



Phosphate of soda 
Ammonio-phosphate of soda 
Phosphate of lime 
Ammonio-phosphate of magnesia 
Neutral phosphate of soda . 
Acid phosphate of soda 



Thudichum. 

(HO,2NaO,P 2 5 )+24HO. 

(HO,NH 4 0,NaO,P 2 0-)+8HO. 

(HO,2CaO,P 2 5 ) 

(NH 4 0,2MgO,P 2 0.)+12HO. 

(HO,2NaO,P 2 0,)+26HO. 

(12HO,NaO,P 2 6 5 )+2HO.) 

G. Bird. 



Robin and Verdeil have pronounced the two salts, last described, to be normal 
constituents of the urine. 



1861.] 



Morland, Uraemia, 



125 



to the integrity of the blood and body. 1 (Liebig, Thuclichum.) The pro- 
portion of earthy phosphates discharged daily is found to be very variable 
in different persons; and, according to the most reliable authorities, no 
average amount can yet be declared. Lehmann, when living upon a mixed 
diet, discharged, on the average, 1.09 grammes, daily; when his food was 
exclusively of an animal nature, the amount became 3.56. a 

Pathologically, the effect of the presence of an unusual amount of the 
earthy phosphates in the system, would depend very much upon the integ- 
rity of the kidneys. If the latter were disabled, and even if not particu- 
larly disorganized — sometimes, even, if nearly healthy — there might be large 
deposition of these substances in various parts of the urinary passages. 
The circulation would in this manner be freed from an embarrassing 
amount of them, but the morbid effects of such an abundant deposit 
would certainly prove very troublesome. Vesical calculi are rarely entirely 
composed of the phosphates. Such is their friable nature and tendency to 
a pulverulent condition, that they prefer a nucleus of some sort, around 
which to accrete, rather than to form pure aggregations of their own sub- 
stance. 

Dr. Thudichum believes that " the originators of the term phosphatic 
diathesis and phosphuria, and their followers, linked a series of the most 
varied disorders together under this term, which had nothing in common 
but one symptom, namely, alkaline urine." (Op. cit., p. 211.) He then 
proceeds to explain in a very clear manner, the reasons for a greater or 
less acidity or alkalinity of the urine. And alkalinity may thus be often 
due to a lack of animal food, by which a suitable amount of acid is usually 
supplied. Therefore the invalid and the poor man are alike liable to pass 
very alkaline urine — the dyspeptic from want of appetite, and the pauper 
from want of means. A vegetable or fruit diet, alone, will make the urine 
alkaline ; and those who cannot digest, or imagine they cannot digest 
meat, and therefore try a vegetable diet, will almost certainly have alka- 
line urine. In anaemia, a meat-diet will soon produce an acid urine, with 
the phosphates, where no acidity existed before. 

It would appear, then, so far as conclusions can at present be drawn, 

1 " There is no known salt the chemical characters of which approach more 
closely to those of the serum of blood than the phosphate of soda ; there is none 
more fitted for the absorption and entire removal from the organism of carbonic 
acid." — Liebig, Researches on the Chemistry of Food, and the Motion of the Juices 
in the Animal Body. Dr. Gregory's Translation, American edition, by Prof. E. N. 
Horsford, 1848. 

2 In connection with the presence of phosphoric acid and of chloride of sodium 
in the system, the following remarks of Liebig have an interest and importance : 
" In some pathological conditions there has been observed (Schmidt, Annalen der 
Chimie und Pharmacie, vol. lxi. p. 329), at points where bones and muscles meet, 
an accumulation of free lactic and phosphoric acid, which has never been perceived 
at those points in the normal state. The solution and removal of the phosphate of 
lime, and therefore the disappearance of the bones, is a consequence of this state. 
It is not improbable that the cause, or one of the causes of this separation of acid 
from the substance of the muscles is this — that the vessels which contain the fluid 
of the muscles have undergone a change whereby they lose the property of retain- 
ing within them the acid fluid they contain. 

" The constant occurrence of chloride of sodium and phosphate of soda in the 
blood, and that of phosphate of potash and chloride of potassium in the jnice of 
flesh, justify the assumption that both facts are altogether indispensable for the 
processes carried on in the blood and in the fluid of the muscles." (Op. sup. cit., 
p. 90.) 



126 



Morland, Uraemia. 



[July 



that a certain amount of phosphoric acid is not only physiologically ne- 
cessary (phosphate of soda), but that certain states of the system require 
additional amounts medicinally, or by food. The ammoniacal urine of 
patients who labour under spinal disease or injury, or who are suffering from 
other affections giving rise to retention and stagnation of the urine, and 
its alkaline change, is referable to a local cause ; and the mischief which 
undoubtedly results to the circulation by reason of this state of things, is 
part and parcel of the causative disease. If inordinate quantities of the 
phosphates are passed for a long time, we should certainly look for sys- 
temic disorder ; and doubtless the general health would soon be found to 
deteriorate. Some specific cause might be detected for such failure — unless 
an unusual quantity of phosphoric acid were being introduced into the 
system, to account both for the large corresponding excretion, and for 
unimpaired health — should the latter be observed to exist. But usually, 
with such a state of things, impaired nervous energy, dyspepsia with irri- 
tability, and various functional disturbances, will be present. 

The extraordinary case reported by Dr. Golding Bird, of the man who 
passed very large quantities of the phosphate of lime, without apparent 
harm to his constitution (excepting that he was always dyspeptic), is 
believed by Dr. Thudichum to be an instance of imposture. There cer- 
tainly seems to be some reason for so regarding it. The patient had been 
under the care "of half the hospital physicians and surgeons in London," 
during fifty years. It is remarked that very possibly he might wish to be 
an object of permanent interest to whatever physician attended him, and 
that he liked hospital quarters. At one time he brought more than an 
ounce of the above-mentioned salt to Dr. Bird, and which he asserted was 
passed from himself. His urine was milky, and abundantly deposited the 
salt, as stated. It is not, however, impossible that he may have been even 
a longer time collecting the large quantity shown to Dr. Bird, than is 
suggested by Dr. Thudichum, viz., sixteen days. The man's health was so 
good that no treatment seemed justifiable, except on account of an appre- 
hension that a vesical calculus might form. 1 Dr. Thudichum does not 
think Dr. Bird's explanation of the case founded on fact f and he refers 
to Dr. Prout's remarks upon this point, as follows : — 

" If the reader should not share our doubts, he may adopt the explanation by 
Dr. G. Bird, for which, however, there is no basis in fact ; or he may explain it 
upon the ground of the following observation recorded by Dr. Prout. (p. 323, 
note.) This physician examined the body of a gentleman who, during the 
greater part of his life, had suffered from renal disease, remarkable for being 
attended by the secretion of large quantities of the earthy phosphates. Both 
kidneys were not only extensively disorganized, but most of the natural cavities, 



1 It would therefore seem that his dyspeptic symptoms were not very urgent. 

2 The following are Dr. Bird's explanatory remarks : " In cases of this kind it 
is very possible that the phosphate of lime is secreted from the mucous membrane 
of the bladder, and not derived from the urine. All mucous secretions contain 
phosphoric acid, combined with earthy bases ; and hence if an excess of the latter 
is secreted with the vesical mucus, it may be washed away with the 'urine and 
form a deposit. This is by no means unfrequent in the irritable bladder, depend- 
ing on the existence of prostatic diseases, &c. : we have a perfect analogy to this 
in the calculous concretions found in the ducts of glands furnishing mucous secre- 
tions. These are all prone to secrete phosphates in too great an excess to be 
washed away with the secretion ; they are therefore retained and form a calculus. 
These, from whatever part of the body they are obtained, present nearly the same 
composition." (Urinary Deposits. Dr. Birkett's edition, 1857, p. 306.) 



1861.] 



Morland, Uraemia. 



as well as many cysts, were found distended with numerous earthy concretions, 
of various sizes and composition. The concretions found in those cavities to 
which the urine had access, consisted of the phosphate and carbonate of lime, 
and more or less of the triple phosphate of ammonia and magnesia, while those 
cavities or cysts distinct from the renal structure, and to which, therefore, the 
urine had no access, consisted of the calcareous phosphate and carbonate only, 
without any admixture of the triple phosphate." (Op. cit, p. 213.) 

When what is termed the "phosphatic diathesis" exists, or when we 
find copious phosphatic deposits in the urine, we are to expect in such 
patients a state of debility, listlessness and exhaustion, mental and physical 
— a sort of cachexia, with disturbed digestion, and an irritable state of the 
digestive organs ; and also, either some manifest or concealed disorder of 
the nervous system. To this condition we have already referred. Such 
symptoms should lead to the adoption of an alterative and tonic treatment, 
and to such examination of the patient hygienically and constitutionally, 
as will doubtless soon afford a knowledge of the chief source of difficulty 
— whether functional or systemic ; and if the latter, whether the cerebro- 
spinal, or renal organs are at fault ; or whether the blood itself be sur- 
charged with matters fit only for elimination. Old people often exhibit a 
train of symptoms indicating troubles referable to what is styled "the 
phosphatic diathesis." Dr. Bird well describes the state when he writes 
that there "is irritability with depression, a kind of erethism of the nervous 
system, if the expression be permitted, like that observed after considerable 
losses of blood." 

It seems peculiarly appropriate to introduce in this place the conclusions 
of Dr. H. Bence Jones in reference to the pathological bearing of phos- 
phatic salts in the economy — much of what we have previously said seems 
to find ratification in these opinions, and perhaps we could not better con- 
clude our examination of this department of our subject than by presenting 
them. 

" 1. No determination of an excessive secretion of phosphoric acid can be 
afforded by the deposit of earthy salts, unless the quantity of lime and magne- 
sia in the food be taken into account. 

"2. No real increase of phosphatic salts occurs in spinal diseases, notwith- 
standing the existence of deposits. 

" 3. In fever, and in most acute inflammations, the phosphatic salts are not 
increased. 

" 4. In old cases of mania, melancholy, paralysis of the insane, or in chronic 
cases of disease in which nervous tissues are uninfluenced, no conclusions can 
be drawn. 

" 5. In fractures of the skull the phosphatic salts increase only when any 
inflammatory action occurs in the brain, and in acute phrenitis an excessive in- 
crease takes place. 

" 6. In delirium tremens there is a marked deficiency of phosphates unless 
they are introduced with the ingesta ; an excess is, however, met with in some 
functional affections of the brain." 1 

In this connection, we cannot but allude to the zealous, and, as it would 
seem, very sensible, recommendation, by Dr. Bird, of what he appropriately 
terms "renal depurants." Knowing, as we do, from unmistakable symp- 
toms, that a poisonous substance is traversing the blood, and thus per- 

1 We transcribe these statements as given in Dr. Bird's volume ; consulting at 
the same time Dr. Jones's papers on the Sulphates and Phosphates, contained in 
the 30th and 34th volumes of the Medico-Chirurgical Society's Transactions. 



128 



Morland, Uraemia. 



[July 



vading all the bodily tissues, it is our manifest duty to use some such 
means for stimulating a sluggish, or even a partially diseased kidney, to 
freer elimination. And there are many substances which may be effectually 
employed in this manner, and innocuously, or even beneficially to the kid- 
neys themselves. Indeed, when there is even some degree of risk in 
demanding extra work from those organs, it is better to tax them rather 
severely, than to allow the accumulation of morbid matters, of any kind, 
in the blood. " The alkalies, their carbonates, and their salts, with such 
acids as in the animal economy are capable of being converted into car- 
bonic acid, including the acetates, tartrates, citrates of soda and potass," 
are properly "renal depurants." (Bird, Op. cit, p. 452.) 

Ammonia. — Symbol: NH 3 ; Equivalent, 17. 0. 1 

Ammonia exists in comparatively very small proportions in fresh and 
healthy urine. 2 Liebig, indeed, doubts whether it can indubitably be pro- 
nounced an invariable and constant constituent of normal urine. In these 
doubts he is joined by Lehmann and Scherer. Dr. Thudichum, who has 
investigated the subject in his treatise already largely referred to, thinks 
the researches of Boussingault more satisfactory than those of Bcecker and 
De Yry ; and that they tend to show the presence of this substance in the 
urine. Neubauer (Journal fur Practische Chemie, Bd. 64, p. 177, and 
Anleitung, § 56), according to the same writer, has afforded the best 
proof, thus far, of the presence of certain amounts of ammonia in the 
urine. His analyses were made by the method of Schlosing. In regard to 
this process, Dr. Thudichum remarks : " There is only one objection to 
this method, which I have already advanced ; the ammonia is set free by 
the addition to the urine of milk of lime. Now, if it can be proved that 
milk of lime, at the ordinary temperature of the air does not within a 
reasonable limit of time create ammonia from urea and the other organic 
substances, we are bound to say that an essential progress would be effected 
by these researches of Neubauer. The subject of ammonia in connection 
with the animal economy would be of immense importance, if it should be 
proved beyond the shadow of a doubt, what Dr. Richardson (Astley 
Cooper, Prize Essay for 1856, On the Cause of the Coagulation of the 
Blood) has endeavoured to show, namely, that ammonia is a regular con- 
stituent of the blood, and the solvent of fibrin in the living body." 
(pp. 219, 220.) 

According to the same author — who again refers to Neubauer's analyses 
for the proof of the assertion — " The ammonia of the salts of ammonia, 
when the latter are taken into the stomach, passes unchanged through the 
system and is discharged in the urine. 17 (p. 223.) 

1 Chemical Composition of Ammonia. 
H 3 = 3.0 17.65 
M =14.0 82.35 



17.0 100.00 

Thudichum. 

2 Ammonia " is the only volatile alkali with which chemistry is acquainted ; 
and of this property we avail ourselves for its analysis." 

" Demonstration of the presence of Ammonia in Urine. — The ammonia, which has 
been liberated from urine by means of milk of lime, is made to pass in the form 
of gas into a solution of sulphate of silver and arsenious acid ; the precipitate 
ensuing is evidence of its presence." (Thudichum.') 



1861.] 



Morland, Uraemia. 



129 



We have cited the above facts— principally of a chemical and physiolo- 
gical nature — because they are not only interesting, but also have an 
important relation to the pathological question which presents itself in 
regard to ammonia considered as a constituent of the urine ; and whether 
its retention in the blood produces any morbid effects. We have not very 
much to offer upon this portion of the subject ; but there are some con- 
siderations which are significant. There is a great deal to be learned in 
regard to the matter — to say nothing of the points in dispute — and prin- 
cipally in reference to the production of uraemia through the agency of 
carbonate of ammonia, as a product of fermentation in the blood. Upon 
this latter question we have already entered into extensive detail, and have 
endeavoured to present the actual status of the subject, as viewed by many 
celebrated and industrious observers. We refer the reader to the portion 
of this essay devoted to Uraemia ; and will merely add, that all who have 
examined the facts and theories advanced by Frerichs and others relative 
to uraemic poisoning, acknowledge the importance of the investigations, 
and also seem fully aware of the conspicuous position which ammonia 
would assume as a morbid agent in the human system, if it should ever be 
proved to possess such a toxic influence as some now accord to it. Dr. 
Thudiehum remarks upon this point : " If what some have ventured to 
bring forward as a defined feature of certain forms of disease of the kidney 
can really be maintained, namely, that the urea retained in the blood may 
there undergo decomposition into carbonate of ammonia, and give rise to 
the symptoms described as uraemia, the pathological indications of ammonia 
in the urine would be all-important in those diseases. And though quan- 
tities of ammonia might be excreted by the lungs, skin, and bowels, yet the 
urine would be that excretion in which the ammonia would be most accessi- 
ble. However probable such a process, under given circumstances, may be, 
actual and direct proof would be required to make it a fact ; and this we 
cannot say to have been afforded by the originators of the theory. We 
know, on the contrary, that the test said .to be diagnostic of the presence 
of ammonia in the breath, the formation of white vapours on contact of 
the breath with a glass rod dipped in hydrochloric acid, frequently fails in 
cases with the most marked symptoms of uraemia. We must, therefore, 
expect further proofs, analyses of the blood and the excretions, before we 
can give that extension to toxaemia as a cause of various severe affections, 
which by various authors has been attributed to it. It is the same with 
putrid or septic fevers, under those conditions in which the blood is said 
to be in a state of dissolution. For all we know, ammonia may be a pro- 
duct of these pathological processes ; and then we might expect to find it, 
in part at least, in the urine." (Op. cit, pp. 224, 225.) 

The opinion of M. Claude Bernard, in his late work (Legons sur les 
Proprietes Physiologiques et les Alterations Pathologiques des Liquides 
de VOrganisme, Paris, Bailliere, 1859), is adverse to admitting that 
carbonate of ammonia is capable of producing toxaemia. We have re- 
ferred to this opinion more at length in another place. (See Appendix, 
Note A.) 

The small quantity of ammonia entering into the composition of the 
normal urine, is, of itself, an element which rather tends to preclude the 
idea of its accumulating in the blood — in cases of retention of the urinary 
ingredients — in such quantities as to prove noxious, even if we consider it 
to be a toxic agent. At all events, under such a supposition, it would 
No. LXXXIII— July 1861. 9 



130 



Morland, Uraemia. 



[July 



require a considerable time for bad effects to arise. And even granting all 
these conditions, the phenomena springing from retention of the other 
more abundant constituents would preponderate ; unless, by that sort of 
"elective affinity" previously spoken of, ammonia alone were seized upon 
and retained in the circulation — the other matters being eliminated and 
excreted. 

Again, it is by no means impossible, although not definitely proved, that 
ammonia may be essential to the integrity of the blood ; in which case, 
any pathological inferences from its presence, unless occurring in very large 
and improbable quantities, could hardly be drawn. And especially in view 
of the fact that the -nature of that ferment supposed by Frerichs to be 
necessary for the production of carbonate of ammonia from urea contained 
in the blood, is yet unknown, must doubt envelop the whole question, 
pathologically, until further experiments shall be made, and its existence 
and real character be ascertained, or its nonentity determined. 

In respect to the question as to the necessity of ammonia to the proper 
constitution and healthy condition of the blood, Dr. Thuclichum has some 
remarks which, under cover of a little pleasant facetiousness, contain 
valuable hints, and may be appropriately introduced in this connection. 
Speaking of the elimination of ammonia — ingested into the system in an 
unchanged state — by the kidneys, he says : — 

" It remains to be seen whether caustic ammonia and carbonate of ammonia 
are eliminated in a similar manner. It remains, also, to be ascertained whether 
the organism produces any ammonia under ordinary circumstances, or whether 
the ammonia in the urine is simply introduced by our food and drink, or by the 
air which we breathe. Some articles of food are rich in ammonia, e. g., radishes. 
The smoke of tobacco contains a large share of ammonia ; and any person 
remaining for any length of time in a room filled with this ambrosial offering to 
Apollo, must inhale such quantities of ammonia as must materially increase the 
ordinary amount in his urine. If ammonia be really essential to the blood, the 
anti-tobacco leaguers may yet hear the argument advanced, that tobacco-smok- 
ing is really essential to keep our fibrine in solution, and that smoking has of 
late become so much more common because the ordinary sources of this 'food,' 
the cesspools, dunghills, and other like accompaniments of human and animal 
habitations, have been done away with. A still greater amount of ammonia is 
of necessity inhaled where both the sources just mentioned flow without 
restraint." (Op. cit, p. 224.) 

The fibrine in the blood of a very considerable proportion of the popu- 
lation of America ought to be in a good state of "solution" if the smoking 
of tobacco be in any degree conducive thereto ! Let us hope that such is 
the effect of "the weed," via combustion and inhalation ! 

Several observers have stated the very small amount of ammonia which 
can be ascertained to exist in healthy urine. 1 Simon (Chemistry, Syd. 
Soc. edit., vol. ii. p. 132) says it "cannot be very easily demonstrated in 
healthy urine." Liebig (Lancet, 1844), referred to by Dr. Day, Editor of 
Simon's Chemistry (loc. cit.), pronounced the presence of ready formed 
ammonia in the urine, as only indicated by "very minute or doubtful 
traces;" and stated also that "these traces probably pre-existed in the 
food partaken of." Dr. Day subsequently remarks: "Experiments for 
the determination of the amount of ammonia in the urine of healthy in- 
dividuals may become of importance in judging of pathological states ; for 

1 "Ammonia exists only in the urine in combination with the muriatic, phos- 
phoric, and lithic acids." (Prout, op. cit., p. 555.) 



1861.] 



Morland, Uraemia. 



131 



in fevers and other diseases, the amount of ammonia in the urine increases 
considerably. It is possible that by analyzing the urine we may, in the 
increasing or decreasing amount of ammonia, obtain a measure for the 
alterations which take place in diseases." 

As has been previously remarked, there seems not to be a sufficient amount 
of evidence from which to educe satisfactory conclusions relative to any 
pathological influence ammonia may have upon the system when present 
therein in unusual quantity. Those who attach such a distinct power to 
it in the production of uraernic intoxication and eclampsia, have yet to 
procure and offer much additional evidence, before their doctrines can be 
unhesitatingly and fully accepted. The preliminary structure certainly has 
a fair and plausible appearance, but needs full development and confirma- 
tion. We have endeavoured to present whatever is available and reliable 
upon the present topic, so far as our means of information permit. 

The examination of the relations of ammonia to the urine and the blood 
concludes the plan originally proposed by us in discussing the subject under 
consideration. It occurs to us, however, that a few words may appropri- 
ately be added relative to the iron and the colouring matter of the urine — 
ureematine. These we will briefly notice under one head. 

Iron and Ureematine. 1 

Iron and ureematine exist normally together in combination 3 in the 
urine. Of course, variable amounts of iron must be found at different 
times in the system, according to the nature and amount of the ingesta ; 
and as the mineral in some of its various medicinal forms is very exten- 
sively used, there must be in many persons a large quantity introduced into 
the circulation. 3 We know the marked beneficial effect of this medication 
in a large class of cases, especially in those of an anaemic and chlorotic 
character, and its employment was doubtless owing, first and mainly, to 
the knowledge of the fact that iron is a normal constituent of the blood. 
That portion of the vital fluid of which it is an integral part, is, as is well 
known, the hsematine or red colouring matter. Chemists have been in- 
clined to believe ursematine "a derivate" of haematine, so great is its 
resemblance to it. (Thudichum et al.) 

But little that is positive can be said upon this subject, as to any patho- 
logical deductions. We can hardly conceive of a sufficient quantity of iron 
being accumulated and retained in the blood — if derived merely from the 
amounts contained in the urine — to prove injurious. It is not infrequently 
observed in practice, that only certain quantities of iron can be medicinally 
ingested, without giving rise to headache, fulness and turgidity of the 

1 Iron: Symbol; Fe. Equivalent; 28.0. 
Ursematine : Elementary composition unknown. 

Thudichum. 

2 Harley ; cited by Thudichum. 

3 Notwithstanding that iron is frequently thus largely ingested, it is a curious 
and hitherto unexplained fact, that it is not found in the liquid excreta. Its mode of 
elimination is therefore unknown. Upon this point, M. CI. Bernard remarks : " Iron 
is the only substance which exists normally in the blood, which has not been found 
in the excreted liquids. How is it eliminated ? This is undecided. A small 
quantity only is absorbed even in medicamentary usage. It has been found in the 
hair; but this is a very slow method of elimination." (Legons sur les Propriety 
Physiologiques et les Alterations Pathologiques des Liquides de VOrganisme, Paris, 
Bailliere, 1859, vol. i. pp. 448-9.) 



132 



Morland, Uraemia. 



[July 



bloodvessels, with other disagreeable symptoms, principally of a plethoric 
nature, and which necessitate, of course, a suspension of the medicine, or, at 
least, a marked diminution of the amount administered. Certain persons, 
also, are far more easily affected by chalybeates than others. In some, 
this amounts to a species of idiosyncrasy which precludes the use of such 
remedies, unless combined with other articles whose employment is often not 
desirable, and sometimes is inadmissible, for peculiar and varying reasons. 
Thus, we know persons whom iron, given in any considerable quantity, 
will purge persistently ; and in some such instances, if opium be combined 
with it for the purpose of restraining the action of the bowels, nausea takes 
the place of the diarrhoea — a species of intolerance of the medicament seems 
to exist. This is doubtless not uncommon. There are other manifestations 
sufficiently indicative of the powerful action of iron upon the system. But 
such phenomena, and those more especially mentioned above, are distinctly 
referable to considerable quantities of iron thrown into the organism at 
once, or gradually. As we have intimated, there appear to be no sufficient 
data whereupon to found any conclusions in reference to a possible patho- 
logical result of retention in the blood of the iron derived from the urine. 1 
With regard to the curative properties of iron in certain affections, the 
statements of Dr. Golding Bird have a peculiar fitness to our subject. He 
says : — 

" Among the remedies which appear most successful when food is not con- 
verted into healthy chyle, and an unhealthy state of the blood from the presence 
of imperfectly assimilated matters results, the preparations of iron deserve no- 
tice. I have repeatedly seen copious deposits of uric acid, in persons of low 
power, completely disappear pari passu with the cure of the pseudo-chlorotic 
symptoms present, by the use of this important drag." 

This is literally " killing two birds with one stone," enriching the blood, 
and depurating it, also. There can be little to fear from iron when judiciously 
administered ; it is to be hoped that any " morbid effects" from large 
amounts existing in the circulation, in whatever way this may be produced, 
will by and by be satisfactorily and fully ascertained and explained. It 
would seem, however, that, had any very marked pathological phenomena 
been constantly, or even frequently, specially dependent upon accumulation 
from urinary obstruction or failure of due elimination, the acumen of the 
numerous competent observers of disease, so continually on the watch for 
such manifestations, would, ere this, have given us some positive ideas upon 
the subject. 

Ursematine. — There are some interesting observations relative to urse- 
matine, which it seems desirable to present at this time. Uraematine is 
believed to be derived, in great measure, from the hamiatine set free during 
the disintegration of the blood-corpuscles, which is always taking place. 
Cholsematine, the colouring matter of the bile, is also considered a product 
of haeinatine. The colour of haeinatine is known to be very persistent. 
The colour of the faeces and urine is ascribed by Dr. Thudichum to " effete 
haeinatine." He also alludes to the fact that iron is always conjoined with 
uraematine as a component element, and considers this as confirmatory of 
its origin from the colouring matter of the blood-corpuscles. 2 

1 " The analysis of the urine may prove useful for determining the amount of iron 
which enters the blood and circulation when it is taken as a medicine." (Thudi- 
chum.) 

1 For methods of ascertaining the quantity of urfematine in healthy urine, the 



1861.] 



Morland, Uraemia. 



133 



Yogel has shown that the amount of ursematine is increased in acute 
febrile diseases ; in those which partake of an anaemic or chlorotic nature 
there is less colouring matter discharged. This is ascribed to the diminu- 
tion of the disintegration process constantly going on, as has been said, 
with greater or less activity. In typhoidal conditions, and in fevers of a 
septical type, there being great dissolution of the blood, the colour of the 
urine is heightened. 

When haemato -globulin e appears in the urine, it is indicative of destruc- 
tion of the blood-corpuscles, and is a sign of serious import. If only tran- 
sitory, however, and not recurrent, the case becomes more hopeful. " But 
when it is a symptom of severe scorbutic or septic disorders, it is a sign of 
great danger to the life of the patient. Suppression of the urine, and dis- 
coloration of the skin, when following the discharge of urine rich in hae- 
matoglobuline, are also very unfavourable, and are forerunners of a fatal 
termination of the case." (Thudichum, op. cit., p. 23?.) 

In discussing a question like that proposed for the subject of this essay, 
there is much to trammel us, on the score of incomplete revelations of the 
chemical and pathological elements concerned. The great interest and im- 
portance of the theme itself, and of the studies and investigations rendered 
necessary for its thorough and progressive examination, will more and 
more rapidly bring hidden truths to light. Practical experiments, and the 
continued observation of those engaged in medical pursuits, were never 
more needed than in elaborating the processes and extending the records 
already so well begun — instituting new methods and employing more pro- 
found scrutiny. And especially to those who have the great advantage of 
being connected with large hospitals, are rare opportunities afforded for 
these pursuits, destined, as they certainly are, to benefit suffering humanity, 
by enabling the members of our profession with more facility and certainty, 
in this class of cases, prius cognoscere, dein sanare. 



Appendix. — Note A. Urea ; questions relative to its agency in the system. 

In a lately published work, 1 M. Claude Bernard discusses the question whether 
urea is to be considered a toxsemic agent, either per se or by any product derived 
from it. The respect which the opinions of this distinguished observer must 
always command, and the very recent date of the conclusions at which he has 
arrived upon this subject, induce us to present such of them as are most essen- 
tial to our purpose. 

"Is urea a poison?" asks M. Bernard, referring to the views of Frerichs. 
A poisonous substance, he goes on to say, althoughit may, like urea, be present 
in the circulation, is not necessarily toxic in every, even the smallest amount. 
" A violent poison may, then, exist in the blood, in very noticeable proportion, 
without occasioning symptoms of poisoning, if elimination be sufficiently rapid ; 

amount passed in twenty-four hours, and much valuable information relative to 
the various shades of colour observed in urine, together with illustrations, see Dr. 
Thudichum's work. Consult, also, Vogel, " Archiv. des Vereins fur gemein- 
schaftliche Arbeiten," Bd. i. p. 137, 1853. 

1 "Cours de Medecine du College de France. Lecons sur les Proprietes Physiolo- 
giques et les Alterations Pathologiques des Liquides de l'Organisme." Par M. 
Claude Bernard, Membre de l'Institut de France, Professeur de Medecine an College 
de France, Professeur de Physiologie Generate a la Faculte des Sciences, etc. etc. 
Paris, J. B. Bailliere et Fils, 1859. 



134 



Morland, Urasmia. 



[July 



we are not, consequently, authorized to declare that urea is not a poison because 
it is formed in the blood in considerable quantities." (Vol. ii. p. 33.) Bernard 
then refers to the experiments of M. Gallois, who found the injection of urea 
into the blood, innocuous, even in large quantities. We must, then, he con- 
tinues, admitting the fact of innocuousness, seek another explanation. The 
theory of Frerichs does not seem sufficient, according to Bernard, to account 
for the phenomena observed. If carbonate of ammonia be injected in small 
quantity into the vessels, there is no result ; and even when introduced into 
the veins of animals in larger amounts, although an extreme agitation was pro- 
duced, yet life was maintained. Carbonate of ammonia, moreover, has nearly 
always been found both in pathological and in healthy blood. "Consequently, 
its presence in the 'blood cannot explain the special accidents of uraemia." 
Bernard therefore adopts another explanation, and puts forward the following 
views in preference to the others referred to. 1. The condition of the kidneys 
in advanced renal disease ; there is softening, breaking down of the tissue — 
"fonte putride." 2. By destroying the nerves going to the kidneys, their dis- 
organization is produced ; softening and purulent formations are brought on ; 
pus is thrown into the circulation ; and thus renal nutrition is wholly perverted, 
the kidneys becoming decomposed. In this state of things, Bernard is inclined 
to ascribe the poisoning of the blood and the resulting phenomena to the 
agency of the putrid matter thrown into the circulation from the injured kidney. 
He admits, however, that new experiments are necessary. Thus, we ought to 
see what effects will be produced by injecting the putrid matter from a kidney 
which has become disorganized by artificial destruction of its nerves, into the 
blood of a healthy animal — in fact we must ascertain whether the accidents 
supervening under such conditions will put on the aspect of the nervous phe- 
nomena of uraemia. 

"There is no physiological office [role) known as especially appertaining to 
urea ; it is a purely excrementitious substance, not a secretion. It is regularly 
eliminated by the kidneys ; when this elimination is interfered with, we observe 
the supervention of grave phenomena, without being able to say whether they 
are, either primarily or secondarily, the consequence of an accumulation of urea 
in the blood, or whether they are dependent upon the lesion which has caused 
the accumulation." The phenomena referred to, says Bernard, have received 
the name uraemia. " Is it proper to class under the same category the con- 
vulsions of lying-in women ?" [as we have seen has been done by Braun and 
others.] This is a question, according to Bernard, which is yet to be examined, 
and which it would be premature to pretend positively to answer at present. 
En resume", Bernard thinks the accumulation of urea, or of carbonate of 
ammonia, in the blood, cannot explain the disorders alluded to ; but that it is 
far more plausible to believe them referable to destruction or injury of the 
renal nerves. 1 [This, however, would not explain the so-called uraemic convul- 
sions of pregnancy, since a sort of artificial, or curable, Bright's disease — cura- 
ble by the act of parturition — may then exist. The question is yet in dispute.] 

Dr. E. Brown-Sequard, in the number of the Journal de la Physiologie de 
VHomme et des Animaux, for January, 1859, makes the following comments 
upon Dr. Hammond's experiments and conclusions : and we are happy to avail 
ourselves of this distinguished physiologist's opinions upon this subject, es- 
pecially in view of the very recent date of their announcement. Dr. Sequard, 
after giving Dr. Hammond's views and processes, as published in The North 
American Medico-Chirurgical Review for March, 1858, goes on to say: "We 
shall confine ourselves to the following remarks : 1. The author has not shown 
so conclusively, as he seems to suppose, the non-conversion of urea into ammonia 
(he employed hydrochloric acid as a reagent); 2. Injection into the jugular vein, 
of substances whose action is sought for, is a procedure very liable to make us 
suppose a non-poisonous substance poisonous, by reason of the disturbance 

1 For Bernard's remarks, in extenso, see the work cited, vol. ii. pages 34 — 37 
inclusive. 



1861.] 



Morland, Uraemia. 



135 



which the injection of any liquid whatever into this vein sometimes produces in 
the movements of the heart ; 3. In dogs from whom the kidneys have been re- 
moved, the injection of four ounces of pure water is capable of producing the 
same morbid effects which the author observed after injecting the different salts 
and urea, contained in four ounces of water. We conclude, then, that Dr. Ham- 
mond's experiments, exceedingly interesting though they are, are not sufficient 
to overthrow the ingenious theory of M. Frerichs. Of the two divisions of this 
theory, that which considers urea not to be a poison, or, at least, not to be ca- 
pable of producing uraemia, seems scarcely to be shaken by the experiments of 
Dr. Hammond. As to the other division, according to which uraemia is a 
poisoning due to the carbonate of ammonia, more powerful arguments than 
those we have cited above have already been urged against it, and, at the present 
time, it seems very probable that uraemia is an aggregation of symptoms de- 
pendent upon various causes, among which, poisoning by carbonate of ammonia 
has only a variable proportion of influence. 

" The experiments of M. Gallois (These inaugurate, Paris. 1859) maybe con- 
sidered more positive than those of the American physiologist, in showing that 
urea is a poison. M. Gallois has seen rabbits die, after violent convulsions, 
from the administration of twenty grammes of urea, introduced into the stomach. 
But we have no proof that urea is not transformed into carbonate of ammonia, 
or into some other toxic element." (Loc. cit.) 

M. Guerard (Diet, de Medecine, in 30 vols., Art. Sang), referring to the ac- 
cumulation of urea in the blood, thus writes : " This accumulation in the blood 
of a principle whose elements are endowed with such an excessive mobility, and 
which separate themselves with the greatest facility in order to transform them- 
selves into carbonate of ammonia, eminently deserves to arrest the attention of 
physiologists, on account of the accidents to which it will unfailingly give rise.'' 
He then asks, "if it be not probable that the ammoniacal odour pervading the 
excretions of those who have long had suppression of urine, is the result of the 
metamorphosis mentioned ? The plausibility of this opinion becomes greater if 
it be remembered that many observers have assured themselves of the existence 
of urea in the fluids effused into the various serous cavities, in persons who have 
died of Bright's disease." M. Guerard refers, in this connection, to Dr. Babing- 
ton. (Cyclopaedia of Anatomy and Physiology, Art. Blood.) 

Note B. — Tlie Relation of Uric Acid to Gout. 

Dr. Barlow (A Manual of the Practice of Medicine, London, 1856), refer- 
ring to the explanation given by Dr. W. Budd (Medico-Chirurgical Transac- 
tions) , in respect to the elective affinity manifested by certain morbific matters 
for certain organs and parts of the body, speaks of the support which the hu- 
moral pathology of the various gouty affections may reasonably derive from 
these views ; but he is by no means inclined to allow uric acid the important 
position of chief agent in the production of gout. He says : " Tt is not, however, 
intended to imply by what has been said, that lithic or uric acid is the alone or 
efficient cause of gout ; for if this were true, we should always have gout when 
uric acid is in abundance [not so, we would remark, if it be in process of elimi- 
nation, and is not retained and accumulated in the blood — for such are the ele- 
ments evidently required for the production of the disease], and never have gout 
without it ; whereas, the presence of the one without the other, especially of 
uric acid without gout, is a matter of everyday experience." [For the reason 
above alleged ; for if uric acid appear in abundance in the urine, we infer from 
the fact alone, as a rule, its free elimination ; consequently, it does not accumu- 
late in the blood, and gout does not occur.] Dr. Barlow continues : " Upon 
what the gouty diathesis or susceptibility depends we know nothing [?] ; it 
manifests itself in the system by an affinity for the gouty poison (uric acid it 
may be) in different parts. Tf this diathesis be such as to produce an affinity of 
extraordinary intensity, there may be a local excess of this substance, without 
any such excess, or even with a deficiency, in the system at large, just as there 
may be a local hyperemia, although the general state of the system may be 
anaemic. This explanation of the difficulty is merely suggested as possible, not 



136 



Morland, Uraemia. 



[July 



enunciated as certain ; it nevertheless derives confirmation from the recent ob- 
servation of Dr. Garrod that uric acid is present in the serum, effused when a 
blister has been applied over a joint affected with gouty inflammation." (Op. 
cit., English edition, 1856, p. 143.) Aside from the force of the evidence ad- 
duced by Dr. Garrod in the test referred to by Dr. Barlow, we cannot think the 
position of the latter author is strengthened by the analogy which he attempts 
to establish — or the similarity which he would imply, in vital action — between 
local hyperemia in general anasmic states and the deposition of urate of soda 
by elective affinity. In fine, in the one case, the blood, although deteriorated, 
does not, in the circumstances proposed, contain a poison ; whereas, in the latter 
case, it does, or the local manifestations thereof would not occur. Mere local 
hypersemia, occurring as above mentioned, cannot be properly compared with 
the local exhibition, by vicarious action, of the product of an abnormal amount 
of uric acid in the blood. 



1861.] 



13T 



REVIEWS. 

Art. X. — A Practical Treatise on Phthisis Pulmonalis ; embracing 

its Pathology, Causes, Symptoms, and Treatment. By L. M. Lawson, 

M. D., Professor of Clinical Medicine in the University of Louisiana, 

&c. Cincinnati, 1861. 8vo. pp. 557. 
The Forms, Complications, Causes, Prevention, and Treatment of 

Consumption and Bronchitis : comprising also the Causes and Pre- 

vention of Scrofula. By James Copland, M. D., F. K. S., &c. 

London, 1861. 8vo. pp. 440. 
Lecons Cliniques sur les Causes et sur le Traitement de la Tubercidi- 

sation Pidmonaire, faites a V Hotel Dieu (1859). Par Noel Gueneau 

de Mussy. Paris, 1860. 8vo. pp. 134. 
The Physical Examination of the Chest in Pulmonary Consumption 

and its Intercurrent Diseases. By Somerville Scott Alison, M. D. 

London, 1861. 8vo. pp. 447. 

It would not be surprising that a disease to which one-sixth or one- 
seventh of the total mortality is owing in a large portion of the civilized 
world, should form a favourite subject of investigation, were it not that all 
the genius and industry expended upon it, and all the suggestions of new 
or modified methods of treating it, have hitherto produced no sensible 
decrease in its ravages. The discouragement inspired by such reflections 
tended, no doubt, to limit the number of special treatises relating to it 
until the introduction of physical methods of examining the lungs rendered 
the distinction of curable and incurable diseases of these organs compara- 
tively easy to duly instructed observers. The brilliant inventions of Auen- 
brugger and Laennec gave a new motive to the study, by shedding upon it 
a novel and unsuspected light, and, illustrated by the cotemporaueous dis- 
coveries of morbid anatomy, revealed every step of the process, from the 
primary alteration of the blood, to the complete disorganization of the 
lungs, in which the material evidences of the disease consist. When there 
was apparently nothing more to learn of the grosser elements of phthisis, 
and the revelations of the microscope and of chemical reagents no longer 
excited the same hopes, which at first they inspired of penetrating the 
arcana of its pathogenesis, the disease acquired a fresh interest, and this 
time a more humane one, in the awakened hope of its curability by medi- 
cinal and hygienic means. Naturally enough this latest phase of the 
subject has been attended with a corresponding activity in the ranks of 
pretenders to medical knowledge; and for every well founded yet cautiously 
expressed hope which physicians have ventured to utter, a score of down- 
right assertions, equally false and positive, have issued from the brazen 
throat of charlatanism. 

So thoroughly has the whole subject been examined that little now 
remains, either in regard to the natural history of phthisis or the value of 
remedies in its treatment, beyond correcting the errors and more precisely 
limiting the truths of the one, and rendering the other more generally 



138 



Reviews. 



[July 



useful. Not that there are not questions still undecided in regard to 
it : but, unless it should enjoy a peculiar immunity from the lot of all 
other subjects,, upon which the reason can be exercised, this must always 
be the case, and the substantial agreement of physicians, both in doctrine 
and practice, will render such dissidences unimportant. Each practitioner, 
and each writer on consumption, will entertain views peculiar to himself, 
and hence every work upon the subject is almost necessarily, and to some 
extent, defective or erroneous. In forming, therefore, our own medical 
opinions, in so far as they are to be moulded by books, we must be careful 
lest, in accepting the sound doctrines they contain, we should become in- 
fected by their errors. Against this danger there is no surer protection 
than in comparing the published results of observation and reasoning with 
one another. Did we possess a personal knowledge of the writers* character, 
it would render unnecessary any attempted estimate of their probity, and we 
should at once reject their evidence, or accept it confidently : but restricted 
as we chiefly are to the written evidence of their veracity, we cannot do 
better than adjust their claims to instruct us by their degree of consistency 
with themselves and with each other. 

The most important among the works whose titles are prefixed to this 
essay, is that of Dr. Lawson. It is the first systematic treatise upon 
consumption of the lungs, by an American author, and we do it but justice 
in stating our opinion that it is not inferior to any other in the English 
language, whether for completeness of elucidation, general accuracy of state- 
ment, or a thorough comprehension of the subject. It is written, also, in a 
style at once simple, clear, and correct. 1 and bears throughout the impress 
of its author" s honest convictions. Indeed, taking it for all in all, it is a 
work which every practitioner may use as a trustworthy guide in forming 
his opinions, and directing his treatment in nearly all the forms and stages 
of tuberculous phthisis. If we thus slightly qualify our general judgment, 
it is because upon certain points we consider the work to be open to 
criticism. These we shall particularly examine, on account of their great 
general interest and practical bearing, as well as because they occur in the 
work immediately before us. 

Dr. Copland"s treatise is substantially the Essay on Pulmonary Con- 
sumption contained in the third volume of his Dictionary of Practical 
Medicine, and, as such, it must be presumed to be familiar to our readers. 
It is essentially a compilation, and although very carefully and diligently 
made, does not present as thoroughly digested an account of the actual 
condition of this department of medicine, nor as much original observation 
as we should have expected from a physician of so much eminence as its 
author. The volume also includes an essay on bronchitis, which it is 
foreign to our present purpose to notice. 

The little work of M. Gueneau de Mussy is an admirable specimen of 
a certain class of clinical lectures, in which a group of cases merely serves 
as the text for a didactic discourse upon a particular disease. This depar- 
ture from the true method and purpose of clinical teaching, which should 
deal with individual cases only, may sometimes be pardoned when, as in 
the present instance, it is not only elegantly and eloquently executed, but 
serves as an occasion for illustrating some important truths. 

1 Several barbarous orthographical errors which must be charged, we are sure, 
to the printer, offend the eye, e. g. jibtr for fibre ; mold for mould : &e. The for- 
mulae are sometimes combinations in various proportions of English and of 
pharmaceutical Latin. They should be one or the other exclusively. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 



139 



In another part of this review we have quoted some not very tender ob- 
jurgations of Dr. Copland against those writers who put too fine a point 
upon the art of physical diagnosis, and who "a hair divide 'twixt north 
and northwest side," in their classification of rales and murmurs. If the 
eminent author had not written his diatribe until after the appearance of 
Dr. S. S. Alison's work, who can tell what fulminations he would have 
launched against it ? A volume of four hundred and fifty pages, on the 
physical examination of the chest in consumption and its intercurrent 
diseases only ! Surely the learned author of the Dictionary of Practical 
Medicine would have found the outrage intolerable, or a bane only to be 
endured when an antidote was at hand, in the shape of Dr. Chambers' 
" Drill for Auscultation," where the whole art and mystery is condensed 
within the limits of a single page, which concludes with this magistral 
sentence: "All besides this is fancy work, showy, but waste of time." 1 
Extremes meet, it is said, and certainly the proverb holds in the present 
case; for, except as furnishing mere indications for the accomplished adept 
in physical diagnosis, Dr. Chambers' " Drill" is as useless to the student 
as the complicated, elaborate, and minute treatise of Dr. Alison, in which 
the true grain lies buried in a bushel of wordy chaff. But while thus ex- 
pressing the feeling of exhaustion with which we have waded through his 
work, stumbling at every step over new-fangled terms which only serve 
to embarrass the reader, how much soever they may illustrate Dr. Alison's 
familiarity with his subject, we should be very unjust were we not to accord 
him a higher place in this department of medicine than is held by any 
English writer, with the single exception of Dr. Walshe, or to give him 
credit for remarkable ingenuity in the invention of useful instruments for 
the exploration of the thoracic organs. Indeed his single improvement 
of the bin-aural or double stethoscope, (which in its simpler form he justly 
ascribes to an American physician, Dr. Cammann,) with the remarkable 
results of its use which he describes, would of itself entitle him to very 
high commendation. To all advanced cultivators of pulmonary and cardiac 
pathology, we very sincerely recommend his work, being well convinced 
that they will find it full of useful, and not a little new information. They 
can afford to look leniently on its neologisms and forms of expression 
which no laws of the English language tolerate ; e. g. " sensorial silence ;" 
"synchronosity ;" "more annihilating;" "ill pronounced bruit;" "divid- 
edness ;" " inflatability ;" "bronchncea" instead of bronchopncea, for 
bronchial respiration; "feeble pipe respiration;" an act of " uno-aural 
audition;" "constrictive character of sound;" "loudish" sound; &c. They 
can even smile at such original comparisons as " a degree of firmness and 
resistance such as that of the white part of a loaf of bread two days after 
it is baked ;" or "as firm as the usual plum pudding ;" or when they are 
told of "the loud, forcible, solid voice;" that in pectoriloquy "the letters of 
each word seem to be distinctly articulated ;" that a percussion blow " is 
lost quoad the lung and air tubes;" of lung "thickly incorporated with 
tubercle;" of "a quasi cracked pot sound;" of "an angle of 180° ;" and 
immediately afterwards of "the angle of a straight line" although the 
qualifying "so to speak" is prefixed to the latter phrase. The uninitiated 
reader would be somewhat puzzled to explain " a double flattened chest" 
and " a single flattened chest ;" and Laennec would bounce in his grave 
at the sound of " buzzing, humming, arrow-root, yarn-tearing, fine rolling, 



1 Lancet, Marcli, 1861, p. 307. 



140 



Reviews. 



[July 



and shell bruits." These and a multitude of similar originalities might 
pass muster, "so to speak," at the bedside, or even in the lecture-room, but 
they disfigure a didactic treatise, and are altogether unworthy of an M. D. 
Edin., F. R. C. P., who dates his preface from Grosvenor Square. 

It would be easy to lengthen the list of recent works on phthisis, some 
of which have received the imprimatur of recognized critical authorities, 
but which are really destitute of every scientific and every moral claim to 
respect ; while others are so redolent of knavery, that when they apply to 
the "Reviews" for recognition, even the gentlest Aristarchus is compelled 
to thrust them out of doors. 

The term phthisis, which is now restricted to tubercular consumption, 
was formerly applied to every wasting disease of fatal tendency, and 
the word tubercle, which at present only signifies a specific morbid deposit, 
was once used to describe every small and rounded body or projection. 
Under the name of laryngeal phthisis, Trousseau and Belloc included 
several different affections, and Dr. Horace Green, of New York, described 
enlarged follicles as "tubercular," which had nothing in common with 
tubercles but their shape. The former error was unavoidable in the exist- 
ing state of pathological knowledge, but the latter is opposed to the 
conclusions of science, and is employed to support a doctrine not less 
erroneous in fact than deceptive and pernicious in its practical results. 
Tubercle is a peculiar morbid product, which is incapable of any higher 
development, and tends either to a retrograde metamorphosis into calcare- 
ous matter, or to softening and elimination. 

Dr. Lawson, after describing the physical characteristics of gray and 
yellow tubercle, says : — 

" It may fairly be questioned whether these products in fact belong to the same 
class, or whether they are not radically distinct in origin, essential characters, 
and ultimate tendency." (p. 34.) 

Dr. C. Radclyffe Hall has also asserted this distinction in terms quite 
as clear and emphatic, declaring that when semi-transparent tubercle be- 
comes opaque, and proceeds towards softening, it does not become cheesy 
like the tubercle, which is yellow from the first ; that tubercle may be opaque 
and yellow from the first; and that, according to Rokitansky, "gray tuber- 
cle never changes into yellow." 1 Whatever qualified opinion the emi- 
nent pathologist just named may once have entertained upon the last 
point, there can be no obscurity about his more matured opinion. We 
find in the last edition of his Pathological Anatomy : — 2 

" There remains no doubt that, as Laennec taught, gray is transformed into 
yellow tubercle. . . . The metamorphosis may commence so early, and advance 
so rapidly, a's to make it seem as if the tubercle had been originally formed 
opaque and yellow." 

Lebert's view differs but slightly from this. He says: " Semi-transparent 
gray granulations are from the first decidedly tuberculous." Yet he adds 
that he has found in the lungs yellow granulations so minute as only to 
be rendered visible by a magnifying power of from ten to fifteen diameters, 
and consequently that they might have been deposited originally as yellow 
tubercles. 3 Yet there is no evidence that these bodies, minute as they were, 
might not originally have been semi-transparent. There is, rather, a strong 
probability that they were so, for there is no reason why they should not 

1 Br. and For. Med. Chir. Rev., Oct. 1855, p. 465. 

2 3d ed. ; 1855, i. 296. 3 Anat. Pathol., fol., i. 329. 



1861.] 



Lawson, Copland, Alison, &c, on Phthisis. 



141 



have undergone the same changes which evidently take place in larger 
tubercular deposits. The greater includes the less. 

Rokitansky, as will be seen below, goes so far as to describe the peculiar 
changes which take place in the appearance of tubercle, in passing from 
the gray to the yellow state, the perfect development of the one, and the 
shrunken and withered aspect of the other ; and Dr. Bennett states that 
the two varieties are composed of similar elements, which are more trans- 
parent and less perfectly defined in the first than in the second sort of 
tubercle. 

Our author states that Bayle, who originally described these gray granu- 
lations, evidently regarded them as different from ordinary yellow tubercles. 
But, as Dr. C. R. Hall has shown, Bayle considered to be tubercles such 
nodules only as were opaque, and by his " granulations" there is to be 
understood "nothing more than isolated, often thickly disseminated gray 
tubercles, which happen to be unusually small, hard, and transparent." 
Dr. Lawson also maintains that " gray semi-transparent granules are in- 
flammatory products," and gives this as one among his reasons for holding 
them to be different from yellow tubercles. But he qualifies this, which 
sounds like a rather bold assertion, since Broussaisism is dead and its caba- 
listic word " inflammation," which was by turns everything or next to 
nothing, has lost its conjuring power, and he implies, if he does not in so 
many words declare, that phthisis is a disease of the constitution, and that 
any cause which debilitates the constitution may provoke the deposit of 
tubercles. It is not singular, then, that local congestions should occasion 
an exudation of the aplastic substance with which the blood is charged ; 
and thus that inflammation should become the occasional, but in no wise 
the efficient cause of tubercular deposits. In other parts of his work (pp. 
145, 1*76, 395), Dr. L. expressly refutes the idea of the inflammatory origin 
of yellow tubercle; and we think that if he had more carefully weighed the 
facts of the case, he would have been less inclined to conclude that semi-trans- 
parent granules are different from yellow tubercle in this respect. For if 
it is certain that these granules always precede yellow tubercles, and if the 
cases where the former exist alone are exclusively those in which death 
takes place at so early a period after the commencement of the symptoms, 
that time for the transformation has been wanting, there is no reason 
whatever why we should not regard gray semi-transparent granulations 
as identical in nature with yellow tubercles, and differing from them only 
as the ripe from the unripe fruit, to use Laennec's comparison. 

The histology of tubercle is discussed by Dr. Lawson in a carefully pre- 
pared chapter, and gives evidence of his own attentive examination of the 
subject ; yet we think that he errs in taking the yellow form as the type of 
tubercle, when the most authoritative investigators have concluded that it 
is an altered if not a degenerated state of the original deposit. Rokitan- 
sky says of this variety: " It consists essentially of nuclei measuring from 
TlJ5 t° t |q mm. in diameter, which are held together by a viscid cement. 
There are, besides, uni or poly-nucleated cells, i. e., mother cells which 
denote an endogenous development and multiplication of the first men- 
tioned elements." (Op. cit., 3d ed.) And, further, in describing the yellow 
variety, he uses this language : " It consists of a great number of protein 
molecules in which the elements of the gray tubercle appear turbid, have a 
yellowish lustre, and are shrivelled, wrinkled, and jagged, and in part, as 
it were, corroded. These are Lebert's tubercle corpuscles." Our author in- 
cludes Rokitansky among pathologists who describe nuclei as being occasion- 



142 



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[July 



ally, but not constantly, present, whereas it is evident from the above quota- 
tion that he regards them as normal constituents of tubercle. Dr. Lawson 
also states that Lebert is one of those " who deny the existence of nuclei," 
whereas, the words of the latter are " rarement on y voit de veritables 
noyaux." 1 This was also the opinion expressed by Rokitansky in the 
first edition of his work ; but it will be seen by the above quotation that 
he now attributes to tubercle elements which are peculiar to bodies capa- 
ble of growth, a conclusion which few will adopt, because it appears to be 
incompatible with. the uniform tendency of the tubercular deposit to a more 
and more degraded condition. The elements referred to by this author are 
peculiar as well as indicative of an inherent power of growth, but Dr. Law- 
son, while admitting them to be organic but non-vascular bodies, describes 
them as being wholly unlike the corpuscles of any other product healthy or 
morbid, or, in other words, as a specific formation. Dr. Ellis, on the other 
hand, 2 pronounces these corpuscles to be only shrivelled cells or free nuclei, 
and that, indeed, tubercle has no special structure. Yet, unable to resist 
the clinical evidence of the peculiarity of tuberculosis as a morbid process, 
he attributes to tubercle powers independent of its ascertained physical con- 
stitution, illustrating his idea by a reference to the operation of morbid 
poisons, as syphilis. It is evident, from this brief statement of the discord- 
ant facts and opinions of those who have most carefully studied the subject, 
that the essential nature and even the primary physical conditions of 
tubercle are virtually unknown. 

The mode of development of tubercle is very clearly, and as we think 
correctly, described by Dr. Lawson. First there is (within or without the 
pulmonary cells) an exudation of a blastema, in which granules or cyto- 
blasts appear ; then each cytoblast becomes invested with a cell membrane, 
and the organic element of tubercle is complete. The cell, however, pos- 
sesses life by means of which it is capable of absorbing nutritive material 
for a limited period, until finally, its vitality being exhausted, disintegration 
results. This change takes place just in the centre of the mass, because, 
being farthest removed from the vascular influence, it will be the first to 
feel the effects of age. As to its nature, Dr. L. adopts the view that it 
consists essentially in fatty, or, as Virchow calls it, cheesy degeneration. 
This idea was, we believe, originally suggested by Mandl, 3 who refers to 
various examples of a similar change which takes place in muscle and other 
tissues when their vitality is greatly lowered. It is not to be lost sight of, 
moreover, that in the formation of adipocere, even dead animal matter is 
susceptible of conversion into a new substance by the operation of moisture 
alone. The idea that semi-transparent tubercle is essentially different from 
the yellow form will perhaps account for the absence of any clear account 
of the origin of yellow tubercle in Dr. Lawson's work, but nearly all other 
writers agree that gray tubercle gradually grows yellow, the change of 
colour beginning in its centre, that it then loses its firmness, is impreg- 
nated with moisture, and finally is disintegrated and liquefied. As Dr. C. 
R. Hall has remarked, softening of tubercle essentially consists of two 
combined modes of disintegration — fatty degeneration and liquefaction. 

In the section on cretaceous transformation, Dr. Lawson calls atten- 
tion to the frequency with which this condition is found in the lungs of 
persons who die of phthisis, and who have also expectorated cretaceous 

» Anat. Path., fol. i. 332. 

2 Am. Journ. of Med. Sci., April, 1860, p. 411. 

3 Archives Gen., 5e ser., iii. 414. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 143 

tubercles. The fact should be particularly borne in mind by those who, in 
their method of treatment, appear to forget that the pulmonary lesions in 
consumption are merely the local expression of a cachexia involving the 
whole economy. In another section the possibility of absorption of tuber- 
cle while in a fluid state is held to be a possible event. It is admitted that 
a demonstration of such a result is in the nature of things impossible, but 
it is suggested that since tubercle is transmissible through the walls of one 
set of capillaries, it may return to the circulation through another class. 
It is not easy to imagine what would be the gain of such a process, for the 
constitutional cause which determined a first exudation would occasion a 
second. Besides, it must not be forgotten that it is probably much easier 
for capillary vessels to secrete a liquid than to absorb a solid, which tuber- 
cle becomes immediately it is deposited. Yirchow contends that tubercle, 
after having undergone a complete fatty metamorphosis, becomes capable 
of reabsorption. Our author alleges that in some cases of commencing 
phthisis the signs of a certain extent of consolidation may be present at 
the apex of the lung, which will afterwards be found to indicate a less 
degree of this change, from which he infers the possibility of the absorp- 
tion of a tubercular deposit. A similar remark has been made by others. 
But they seem to forget that the signs in question may all depend upon a 
limited pneumonia which is excited by the presence of the tubercles, and 
assumes that subacute form which intercurrent pneumonia of limited 
extent affects. That such is often the cause of a temporary aggrava- 
tion of the symptoms and an extension of the space embracing the 
characteristic physical signs of solidification cannot be called in question. 
It is also conceivable that in acute tubercular infiltration the liquid por- 
tion of the effused blastema may be absorbed ; but there is no reason to 
suppose this possible in reference to the proper tubercular elements ; and, 
moreover, this exudation which usually occurs at the apex of the lung takes 
place in the primary development of the chronic disease, and therefore 
slowly and not probably in sufficient quantity to occasion the physical signs 
in question. When clicking and dry crackling sounds are alone tempo- 
rarily increased, without any corresponding increase in the area of dulness, 
we have been accustomed to attribute the phenomena to a limited tuber- 
cular capillary bronchitis, which would seem to be a more probable expla- 
nation than the presence of a glutinous exudation of tubercle in the air-cells. 
We are quite willing to admit, hypothetically, the possible occurrence of 
physical signs of tubercle at the apex of the lung followed by their total 
disappearance, and depending upon a tuberculous exudation in its primary 
form, because pathological anatomy exhibits to us occasionally cretified 
tubercles which have failed to furnish any physical evidence of their presence ; 
but we repeat that there exists no clinical evidence whatever to show that 
tubercle once formed can ever be removed by absorption. 

Dr. Lawson is of opinion that the cretaceous transformation of tubercle 
is only due to the absorption of its animal matter, and not at all to the 
substitution of mineral elements. The latter is, however, the opinion of 
Copland, and by inference that of Lebert ; and we cannot see why it should 
not be true when we consider how numerous are the cretaceous transforma- 
tions of fibrinous exudations, and various tumours, including hydatids of 
the lung in the lower animals, as Mandl points out. Thenard found that 
crude tubercle contains only three per cent, of mineral matter, while 
calcified tubercle contains ninety-six per cent. It has, indeed, been sug- 
gested that this proof is insufficient unless we know that the original tuber- 



144 



Reviews. 



[July 



cle had not dwindled in size to a corresponding degree. That it should 
have been originally thirty times larger, which the explanation requires, 
is, however, totally incredible. Moreover, as Dr. C. R. Hall remarks, 
among tubercles on serous membranes we frequently find a calcareous 
nodule as large as any of the neighboring little tubercles, in which it is 
plain that there is more of earthy matter than could have belonged to the 
original deposit. 

Dr. Lawson describes with great clearness and accuracy the formation of 
cavities, and the condition of the bronchi and pleura, but omits all notice 
of the laryngeal lesions. In speaking of the distribution of the deposit, 
he distinguishes between "true tubercle" and semi-transparent gray granu- 
lations, as he does in those portions of the work already noticed, and we 
cannot but repeat that this view is at variance with the most authoritative 
teachings of pathological science. In the chapter on pneumonia in its 
relations to phthisis, the modifying influence of the tubercular constitution 
and of tubercular deposits upon the grade of pneumonic inflammation is 
well portrayed, and a distinction correctly drawn between this form of 
pneumonia and that more limited inflammation of the lung which is directly 
excited by the presence of tubercles. We cannot, however, subscribe to 
the statement that pneumonic inflammation of the apex " is observed in 
the mere diathesis, anterior to the development of tubercles." The proof 
of such a proposition would, we suspect, be difficult to furnish. It would 
be scarcely less so to demonstrate that in many cases the extent of tuber- 
cular deposits in the lungs is regulated by pleuritic adhesions. Such is 
the author's statement in opposition to the settled belief that pulmonary 
tubercles themselves excite pleurisy, and very generally to an extent equal 
to that which they occupy in the lung. He believes rather that the dimin- 
ished action of a lung compressed by a pleuritic effusion favours the deposit 
of tubercle within it. But the two propositions do not necessarily exclude 
one another. Of the first an all-sufficient proof is the extreme rarity of 
pleuritic adhesions of the upper lobe of the lung independently of tubercle 
in that part. The clanger of tubercular pleurisy is undoubtedly great, as 
every medical observer will attest. But Dr. Lawson says: "We can 
scarcely assent to the conclusions of Louis, when he asserts that, with one 
exception, he never knew it entirely cured !" Upon this it may be remarked, 
first, that Louis does not state a conclusion, but a fact, and further that he 
expressly qualifies his statement by the remark : "Of course I refer only to 
grave cases of pleurisy, such as are accompanied with more or less effusion ; 
as for dry pleurisy, it is probably without influence on the progress of the 
disease." The influence of pleuritic effusion upon the condition of large 
cavities is occasionally favourable ; the compression of the affected lung tends 
to diminish the wasting discharge, and, under favourable circumstances, may 
even promote the cicatrization of the part. Two cases are reported, the 
one of pleurisy and the other of pneumothorax, in which this effect seems 
to have been produced. 1 

We may here remark that in the work before us no special notice is 
taken of pneumothorax in connection with phthisis. Speaking of emphy- 
sema in phthisis, Dr. Lawson, after alluding to the obliteration of the 
cells by tubercle, says: "Following this condition the adjacent parts take 
on increased action, and finally become emphysematous." This statement 
does not harmonize with a previous and correct one that emphysema gene- 

1 Med. Times and Gaz., Aug. 1860, p. 108. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 



145 



rally occurs in parts of the lung free from tubercular deposits. Besides, it 
is difficult to comprehend how any portion of a lung can "take on increased 
action." Undoubtedly dilatation of the vesicles in phthisis is attributable 
chiefly to the mechanical effect of coughing. Dr. L.'s observations agree 
with those of Louis and Rokitansky, in snowing the heart to be smaller 
than natural in phthisis. It is difficult to comprehend how an opposite 
conclusion could have been arrived at by Hasse and Dr. Boyd. 

The chapter on the nature of phthisis affords a very favourable display 
of our author's literary research and critical skill. He deals very justly, if 
not always very gently, with the hypotheses invented by ingenious men to 
give a scientific colouring to their speculations or their practice. He thus 
condemns in succession the theory of impaired primary digestion, those of an 
imperfect development of chyle, of a morbid condition of lymph, of defective 
respiration, of morbid states of the blood, of a specific poison, of changes 
in the condition of the albumen and fibrin, of retrograde morphology, 
of derangement of the organic nervous power, and of inflammation. A 
very curious piece of reasoning upon this subject is of frequent occurrence in 
the writings of distinguished medical authors. Many of them speak of 
scrofula and consumption as if they were essentially the same disease ; and, 
among the sub-titles in Dr. Copland's work, we read "the prevention of 
the scrofulous taint, the chief source of consumption," yet this writer agrees 
with Dr. Lawson, Dr. Walshe, and indeed almost every competent author- 
ity, in declaring 

" That the manifestation of scrofulous or tubercular disease in the bones or 
glands, &c, in childhood or youth . . . generally prevents the occurrence of 
tubercular consumption." (p. 173.) 

It is very true that the microscopic and chemical as well as the gross 
physical qualities of scrofulous matter and tubercle are the same ; but the 
entire symptomatology of scrofula is different from that of phthisis, the 
one affecting the lungs almost exclusively, and the other quite as exclusively 
being seated in organs in which tuberculosis apart from phthisis is rare, as 
the joints, the eyes, the skin, the subcutaneous cellular tissue, and the mu- 
cous membranes. Childhood is the age of scrofula, manhood of consump- 
tion ; Northern and Middle Europe is the region where scrofula and phthisis 
both abound ; while in this country, where the mortality from the latter dis- 
ease is not less than on the other side of the Atlantic, scrofula is compara- 
tively a rare affection among the native population. As Lebert declares, 1 
there is no identity between the two diseases. 

The most plausible of the theories above referred to is that of impaired 
primary digestion. 

Morton 3 enumerates among the symptoms which denote the imminence of 
phthisis, a continued want of appetite without apparent cause, inability to 
digest the food, and, if much is eaten, oppression at the stomach and 
weariness of the limbs. This, he adds, "is the very symptom that opens 
the way to a consumption." Dr. Copland refers to Tissot, as having 
indicated the relations of indigestion to consumption, and quotes from 
Dr. A. Smith a passage which appears to warrant this statement. But, 
on referring to Tissot's works, 3 we find that the first portion of the quota- 
tion has no reference to pulmonary or digestive disease, but only to mental 

1 Haudbuch der praktischen Medicin, I. 511. 

2 Phthisiologia, p. 70. 

3 (Euvres Compl. torn. iii. p. 28 and p. 58. 

No. LXXXIIL— July 1861. 10 



146 



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[July 



excitement ; and the second is a paraphrase of a passage in which, indeed, 
vitiated blood is said to be a cause of consumption in persons of sedentary 
habits, but there is nothing to imply that its vitiation is the effect of indi- 
gestion. Dr. Copland, however, holds that indigestion is an early attend- 
ant upon all the forms of the malady, but by this he does not so much 
imply gastric dyspepsia as deranged assimilation and nutrition, a condition 
which, we presume, can only be inferred to exist by the occurrence of ema- 
ciation. Dr. E. Lee 1 tells us that many children and many patients who 
have passed the age of puberty become consumptive although digestion is 
well performed, and on the other hand but few dyspeptics become consump- 
tive, unless predisposed to the disease, or exposed to some one of its active 
causes. Dr. Walshe says: "I have not met with any marked illustration 
of the lamentable details concerning phthisical dyspepsia supplied by some 
authors," but he coincides with Dr. Copland in recognizing the patent fact 
that the secondary processes of digestion are at fault. We can but repeat 
that this fact is expressed in ordinary language by the word emaciation. 
Dr. Budd has carefully described the gastric derangements accompanying 
phthisis, 3 as Louis had long ago done; but neither of these writers refers 
to dyspepsia as preceding the pulmonary and general symptoms of con- 
sumption. Dr. Flint has observed no connection between dyspepsia and 
tuberculous disease of the lungs, but on the contrary is disposed to regard 
the existence of the former as rendering that of the latter improbable. 3 
De Mussy remarks that indigestion is a symptom common to all serious 
diseases, whether acute or chronic, and although it often attends the com- 
mencement of phthisis cannot be said to produce it. 4 

Our author has examined this question with particular care. He points 
out the want of agreement among those who adopt the affirmative, and 
dwells upon the conclusive fact, cited as we have seen by others, that, as a 
general rule, dyspepsia does not exist in persons who become the subjects 
of tubercular consumption, and that on the other hand dyspepsia is an 
extremely common disease where there is no evidence either of the diathesis 
or of the existence of phthisis. 

"We feel authorized," he concludes, "to reject the gastric theory as wholly 
incapable of explaining the origin of many, or even of any large proportion of 
cases of phthisis ; but, as a mere symptom, or in a therapeutical point of view, 
the derangements of digestion become vastly important." 

As for the theory which refers tuberculosis to a defective elaboration of 
chyle in consequence of a disturbance of the normal relations between fat 
and albumen, which is supposed to result in the imperfect formation of the 
chyle-corpuscles, a theory which has been very ingeniously advocated by 
Dr. Bennett, our author very pertinently objects to it that we have no 
proof of the assertion that tubercle depends on an absence of the fatty 
element, or that an excess of acid exists in the stomach of persons attacked 
with phthisis, so as to impede the assimilation of fat. He might have 
added, further, that many consumptive patients do perfectly digest fatty 
food, and increase in weight by the use of it, while all the time the tuber- 
culous degeneration of the lungs is steadily advancing. 

While rejecting the theories above referred to as sufficient explanations 
of the origin of tuberculosis, Dr. Lawson very properly concedes the occa- 

1 Fiske Fund Prize Essay, p. 35. 

2 Med. Times and Gaz., Aug. 1858, p. 131. 

3 Dis. of the Respiratory Organs, p. 496. 

4 Op. cit., p. 30. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 147 

sional agency of the causes which they embrace in developing the disease, 
while he regards thern as being still more commonly effects or symptoms of 
the primary lesion. His own speculations upon this subject constitute a 
very interesting episode in the work, and are adapted to inspire an extremely 
favourable opinion of the author's pathological knowledge and dialectic 
skill. A brief summary of them will not be uninteresting. 

Dr. Lawson sets out by selecting for examination those cases only of 
phthisis in which the disease has been developed by its own inherent power 
rather than under the influence of external causes. All matters contained 
in the blood, and which cannot be assimilated, are eliminated through cer- 
tain organs rather than others, e. g., the typhoid poison through Peyer's 
glands, that of the eruptive fevers proper through the skin, diabetic sugar 
through the kidneys, &c. In each of these diseases we see the same group 
of phenomena recurring in the same way, and hence we must conclude that 
in each case a specific cause is in operation. Xow tuberculosis is a specific 
affection, and very probably, though not demonstrably, tuberele is a specific 
materies morbi. It certainly is "a specific or peculiar product wholly unlike 
fibrin, albumen, casein, or other known compounds." Dr. L. shows that 
it does not originate probably in the chyle or the blood, and consequently 
that it must have its origin in the metamorphosis of the tissues. The 
products of this process are nitrogenous and carbonaceous ; the former are 
eliminated by the kidneys, and the latter in part by the lungs. Here the 
author concludes, that the metamorphosis of the tissues may give rise to 
an elementary form of tuberculous matter of so subtle a character as to 
elude the researches of the chemist and the microscopist, but which may 
accumulate in the lungs. He admits that this is a hypothetical view, but 
adduces in its defence the analogies drawn from diseases admitted to depend 
upon a virus, which, however, cannot be detected in the blood, and also 
the observation that even when urea is known to exist in the blood of ani- 
mals subjected to appropriate experiments, a certain time must be allowed 
for it to accumulate after its escape from th'e kidneys has been prevented, 
before its presence in the circulating fluid can be demonstrated. 

The identity or close similarity of scrofula and phthisis, which he main- 
tains in common with the greater number of pathologists, but in opposition 
to Lebert and others, furnishes an argument in support of his doctrine. In 
the latter, he affirms, the morbid element enters the venous radicles and 
reaches chiefly the lungs ; in the former, it enters the lymphatics and affects 
the glands. ISow, as the two affections rarely coexist, as indeed for the 
most part they occur originally at different periods of life, it is not impro- 
bable, says Dr. L., that the manifestations of scrofula in the skin, glands, 
&c, may save the lungs from a development in them of tubercles. He 
does not suggest any reasons why the two forms of disease should occur 
at different ages, but one might perhaps be found in the great development 
of the lymphatic system in youth ; nor does he consider the obvious objection, 
that tuberculosis, as distinguished from scrofulosis, is very common even 
from intra-uterine life through all the stages which precede adult maturity. 

The formation of a specific tubercular substance, and its elimination with- 
out deposit in the tissues, constitutes for Dr. L. the "precursory stage" of 
phthisis, and it would be quite consistent with the hypothesis to suppose that 
accidental circumstances, aud among them inflammation of the lung substance 
itself, might cause a deposit of tubercle which else would have escaped. 
This, however, our author does not venture to assert, but candidly admits 
that the deposit is not the product of ordinary inflammation. We would 



148 



Reviews. 



[July 



suggest that it is in accordance with his hypothesis that tubercular deposits 
should occur most frequently at the summit of the lungs, for that is the 
part least moved during respiration, and further that the disease is pretty 
certainly most common among those persons whose habits are inconsistent 
with the free play of these organs. 

The conditions which favour the development of tubercle, or, in general, 
the Etiology of Tuberculosis, forms a very interesting chapter in the his- 
tory of the disease, and one indeed which calls for even a more thorough 
study than the disease itself, because from it we may perhaps learn how to 
prevent what our therapeutic means are incompetent to cure. In study- 
ing the influence of climate, Dr. Lawson makes a remark upon a point which 
has too generally been disregarded, which is that this influence is to be 
measured not by the sickness and mortality of travellers, troops, and other 
foreigners, but by those of the natives of any place. He also calls atten- 
tion to the important fact that the disease is most prevalent in the tempe- 
rate regions of the globe, but comparatively rare in the Torrid and Frigid 
Zones. Within the former there is no place free from the ravages of con- 
sumption, and often, as at Nice, its endemic mortality ranges very high 
even in a climate which is considered propitious to strangers who are suffer- 
ing from the disease. In Asia it appears to be comparatively infrequent, 
and in Africa even more so. The elaborate tables prepared by the author 
from the U. S. Census of 1850 show that in the Eastern States the pro- 
portion to the population of deaths by phthisis is 1 : 347 ; in the Middle 
States 1 : 548 ; in the Western north of the Ohio 1 : 911 ; in the Western 
south of the Ohio, 1 : 1585; and in the Southern, 1 : 1898. Hence the 
mortality from phthisis increases progressively from South to North, and 
is nearly five times as great in N. England as in the S. W. States. 

Another great fact which has been brought out by the climatological 
investigations of recent years, is that dryness of the atmosphere is the one 
element which renders a climate inapt to generate tuberculous diseases, and 
moisture the one which, whether associated with heat or cold, is the agent 
which chiefly develops and fosters them. 

In the section on "Occupation in relation to phthisis," Dr. Lawson refers 
to the inhalation of irritating particles as a cause of the disease : although 
he subsequently remarks that in the absence of both the hereditary diathesis 
and the acquired predisposition, this cause will be far more likely to develop 
simple inflammation than tubercles. Indeed, he quotes Dr. Holland, of 
Sheffield, to prove that phthisis is the least frequent among the various 
pathological conditions which occur in the grinders of that city. As the 
class of facts here referred to bears upon the question of the influence ex- 
erted by inflammation and irritation in producing tubercle, it may not be 
amiss to refer to some of those which are directly related to it. Dr. Alison 
states that "there is hardly an instance of a mason employed in hewing 
stones in the vicinity of Edinburgh, living free from phthisical symptoms 
to the age of fifty. Nevertheless, tubercles were not found in the lungs of 
those who were examined after death." Dr. J. C. Hall, whose opportu- 
nities for studying the affection in Sheffield itself were peculiarly great, 
says, "there is no necessary connection between this disease and thoracic 
consumption. It is possible the two diseases may exist in the same indi- 
vidual, but the connection is purely accidental." 1 And he remarks again, 
"the disease is in fact chronic bronchitis, followed as a matter of course by 



On Thoracic Consumption, p. 49. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 



149 



dilatation of the tubes, and, at last, inflammatory destruction and excavation 
of the substance of the lung takes place." A precisely similar and detailed 
description is furnished by M. Desayvres of the disease which affects the 
grinders at the manufactory of arms at Chatellerault. 1 Oppert, also, speak- 
ing of the analogous disease affecting coal miners, remarks that it occurs 
without as well as with tuberculosis, and appears to exert rather a favour- 
able influence upon the latter. 3 

Our author quotes Dr. Peacock as stating that the particles inhaled by 
the workers in French burrstone " are remarkably prone to induce phthisis, 
and especially so if any constitutional predisposition to the disease exist." 
But there is nothing in the paper referred to, 3 nor in a subsequent report by 
the same author, 4 to prove the special influence of the directly irritant cause 
in producing tubercular disease. This, as well as the confinement, damp- 
ness, and fatigue, attendant on their labour, and the dissolute habits in 
which the workmen indulge, are all causes of a depressing nature abundantly 
sufficient to develop consumption in those who are predisposed to it, and 
it does not appear that more cases of this disease occur among them than 
can be thus accounted for without invoking direct mechanical irritation, 
which in the majority of cases produced fatal effects without the interven- 
tion of tubercular disease. 

In the chapter upon Ingesta in relation to phthisis, Dr. Lawson makes 
the following statement : — 

" It has been estimated that the inhabitants of Paris consume six times as 
much animal food as those of London, and yet consumption is more common in 
the former than the latter city." 

We can not but ask ourselves whether the order of naming the two cities 
has not been inverted. The English are as proverbially beef-eating as the 
French are bread-eating ; and the ordinary statements of mortality from 
phthisis show Paris and London to be in this respect upon an almost 
equally bad eminence. (Casper.) 

In examining the influence of alcoholic drinks upon phthisis, Dr. Lawson 
makes the just remark which intemperate apostles of temperance would do 
well to heed, that the effects of the use and the abuse of these drinks are 
constantly confounded. He shows that several independent observers have 
found in post-mortem examinations of intemperate persons a much smaller 
proportion of tuberculous deposits in their lungs than in those of other 
persons. He remarks, further, that it is not easy to separate the influence 
on the health of intemperance and its attendant evils, the exposure, fatigue, 
bad and insufficient food, &c, and that if alcoholic drinks do really con- 
tribute per se to the induction of phthisis, we ought to find among its 
votaries who have been ruined by it in health and estate an excessive pro- 
portion of deaths by consumption. But this result, says Dr. L., has not 
been observed ; on the contrary, we may add, the conviction is strong that 
the very opposite result has been produced. It has not been remarked, 
so far as we know, that the temperament and constitution which lead to 
the abuse of alcoholic drinks are antagonistic, as it were, to those which 
belong to the phthisical diathesis. The sanguine are fond of excitement 
and of the associations which lead to convivial excesses ; but the nervo- 
lymphatic, of small appetite and feeble digestion, and who court quiet and 

' Archives gen., 5eme ser., iii. 718. 2 Prager Vierteljahrs., lxi., Anal. 26. 

3 Br. and For. Med.-Chir. Rev., Jan. 1S60. 

4 Med. Times and Gaz., Oct. 1860, p. 418. 



150 



Reviews. 



[July 



loneliness rather than scenes of boisterous mirth, are the predestined victims 
of consumption. If these persons fall into habits of intoxication, they 
rapidly become dyspeptic, wasted, and feeble, and tuberculosis soon follows. 
Those of the other class, on the contrary, are more liable, as Dr. L. re- 
marks, to fall victims sooner or later to diseases of the digestive organs, the 
kidneys, or the brain. Dr. N. S. Davis, of Chicago, 1 has endeavoured to 
throw light upon this inquiry by ascertaining the previous habits in regard 
to alcoholic drinks in 210 cases of consumption. But evidently they are 
not pertinent to the matter. As stated, they were all cases of phthisis. 
Now the question is not how many out of a certain number of consumptives 
indulge in alcohol, but how many out of a certain number of alcohol drink- 
ers become phthisical, and whether that number represents a greater or a 
less proportion than become so among persons who eschew alcohol in every 
shape ? A definite answer would, we suspect, be impossible, but the ele- 
ments for making an approximative one are stated above. 

The relation of inflammatory affections of the lungs to tubercular con- 
sumption is a very interesting one. It was very natural, before the true 
nature of the disease was understood, and afterwards even until the means 
of detecting its earliest traces were discovered, that diseases which had so 
much in common as chronic bronchitis, chronic pneumonia, and chronic 
phthisis on the one hand, and on the other the acute forms of these dis- 
eases should be mistaken for one another. Every one acquainted with 
physical diagnosis is called upon, even now, to witness similar blunders of 
incompetent physicians, to see phthisis mistaken for bronchitis, and to 
learn how readily the error may be committed of attributing the former to 
an original attack of the latter. Morton, with his characteristic sagacity, 
avoided it ; yet he did not fail to recognize the fact that acute phthisis is 
sometimes lighted up by pulmonary inflammation. His words are these : — 

" It is easy to observe that a dry cough and a very acute consumption do often 
come from an inflammation of the lungs, a pleurisy, or some other disease of the 
lungs. ... In those places where the inflammation has before for some time pre- 
vailed, there are hard tubercles to be found, dispersed up and down, together 
with a dry cough and a continual hectic fever ; from whence such patients being 
once seized with a very acute consumption, die within a few weeks." 2 

And that other greatest among the masters in this domain, Laennec, 
makes use of the following exquisite illustration : — 

" And thus, to avail myself of a metaphor which is, perhaps, not so foreign 
to the present subject as at first sight it may appear, on land which is worked 
after having long lain fallow — or been left to itself after several years of culture 
— we may observe that a multitude of seeds germinate, which for years had been 
concealed in its bosom." 3 

Morton would appear to have thought inflammation the efficient, but 
Laennec only the occasional or exciting cause of tubercles. Laennec regarded 
even this coincidence as rare, declaring that in nineteen-twentieths of the 
cases in which the two conditions existed, the inflammation was excited by 
the presence of the tubercles. Louis dwells particularly on the different 
seats occupied by inflammation and by tubercle in the lung — the former 
occupying the lower, but the latter the upper portions of the organ. Gri- 
solle enters more fully into detail, particularly as regards pneumonia, and 
proves that phthisis rarely follows immediately upon pneumonia ; that even 

1 Trans. Am. Med. Assoc., xiii. 565. 

2 Op. cit., p. 91; vide, also, p. 121. 3 Op. cit., ii. 71. 



1861,] Lawson, Copland, Alison, &c, on Phthisis. 151 



then there is more reason to believe the latter an effect of tubercles than a 
cause of them; and that in infinitely rare cases where miliary tubercles have 
appeared to be developed in a hepatized lung, the pneumonia has acted as 
an exciting and not as the efficient cause. Dr. Copland states that frequent 
attacks of inflammation of the lungs may develop phthisis in scrofulous and 
lymphatic persons, but that it is not necessarily a consequence of these 
affections. Lebert declares that they rarely have such an influence, and 
adds, " I am unable to comprehend how so unfounded an assertion came to 
be received as a general dogma, were it not that the most of our observers 
are too much afraid to open their lips to gainsay any of the numerous 
popes who fabricate articles of faith for our medical creed." 1 M. de Mussy 
is among those who regard the acute inflammatory affection as some- 
thing more than an agency which, acting on the system at large, merely 
arouses the latent tuberculous diathesis into action. He says, " Under the 
influence of the diathesis this morbid irritation of the lung, instead of 
terminating in resolution, ends in the production of a heteromorphous de- 
posit, the tubercle." It is sufficient to reply, as has been done ever since 
the days of Bayle, that bronchitis affects the lower lobes of the lungs, but 
tubercles are deposited at their summits. With the decisive opinions of the 
great masters in pathology against the doctrine in question, and our own 
observations in full accordance with theirs, we cannot subscribe to the con- 
clusion which Dr. Lawson draws from his experience : " That a large 
number of cases of phthisis have their starting-point in an inflammatory 
affection involving some of the pulmonary structures." (p. 2T6.) His own 
illustrations do not, we think, sustain him in this position ; and, we may 
add, his own expressions in other places. Thus, when speaking of the 
alleged inflammatory origin of tubercles, he says : — 

" All of the phenomena of the disease pointedly contradict this hypothesis." 
(p. 145.) And, again : " While we admit, therefore, the occasional occurrence 
of tubercles as a sequence of pneumonia, independent of a diathetic state, it 
must be stated that such a result is most usually met with in those having some 
hereditary predisposition to tuberculosis." (p. 278.) 

To this, no objection can possibly be made. It must be admitted that 
certain forms of disease tend to develop tubercles in the lungs, but they are 
not exclusively, nor even principally such as spend their force upon these 
organs. 2 

The influence of malaria upon phthisis has been much discussed of late 
years, and a belief in its beneficial or antagonistic qualities been very 
strongly expressed by Dr. Walshe. After a candid discussion of the prin- 
cipal data of the question, Dr. Lawson arrives at an affirmative conclusion, 
and states his belief " in some degree of antagonism between marsh mias- 
mata and tuberculosis." It would seem, on the whole, however, that the 
remedy, if it be one, is worse than the disease ; for death by phthisis would 
be far preferable to dragging out a life rendered wretched and intolerable 
by the cachexia of marsh malaria. In analyzing the materials made use of 
by writers upon this topic, we have been struck with the frequent references 
made to malarious localities, in which it is said phthisis is of rare occur- 
rence, without, however, any reference to their being situated in warm 
regions, where, under a general law, phthisis must be comparatively infre- 

1 Handbuch, ii. 139. 

2 The essential independence of tuberculosis and inflammation is demonstrated 
in an able paper by Samuel Lewis, M. D., in the Philad. Med. Exam., March, 1854, 
p. 14o. 



* 



152 Reviews. [July 

quent. All such instances, it is evident, have no bearing upon the ques- 
tion. Nor is it sufficiently clear that one reason of the apparent immunity 
from phthisis of the inhabitants of certain places is not the death by mala- 
rious diseases of the greater number of those who, from constitutional de- 
bility, would have been the fated victims of consumption. Dr. Lawson 
does not refer to a valuable paper upon this subject, by Dr. Peacock, 1 who 
sums up the matter in these words : — 

" The correct inference would appear to be that the influence, if any, exerted 
on the prevalence of consumption, by a malarious atmosphere or by ague, is far 
less important than that of various other causes which affect the development 
of that disease. The practical conclusion also to be arrived at is, that as phthisical 
patients may take ague, and as such complication materially aggravates the 
original disease, we should, in selecting residences for consumptive patients, 
avoid those situations which are marshy, or in which aguish affections are 
known to prevail." 

The contagion of phthisis is a subject not alluded to by Dr. Lawson. 
Dr. Copland reminds us that the disease is stated by Aristotle to be conta- 
gious, and that Baillou mentions its being communicated by patients to 
their nurses ; he also adds that emanations from persons in the second and 
third stages of the disease " are certainly sometimes productive of consump- 
tion," and he rebukes the scepticism of those who think themselves " strong- 
minded" because of their incredulity. Morton declares that, like a conta- 
gious fever, it does infect those that lie with the sick person. Laennec 
reminds us that Morgagni was so persuaded of its contagiousness, that he 
dreaded to examine the bodies of those who died of it ; and, after relating 
how in other countries it is popularly believed to be contagious, and that 
the bedding and clothing of the deceased are destroyed by fire in order to 
prevent this evil, he adds, with a touch of banter, that "in France, at 
least, it appears not to possess contagious qualities." He then relates how, 
twenty years before, he accidentally inoculated himself on the hand, while 
dissecting a tuberculous bone, and in the course of a week a little tumour 
formed, which, on being cauterized, discharged a mass which closely resem- 
bled yellow crude tubercle. We recall this anecdote for the purpose of ap- 
pending to it M. de Mussy's commentary: — 

" Laennec," he says, " was inoculated with tubercle, as were Alibert and Biett 
with cancer. Because there were no local effects, all three concluded that these 
diseases are not transmissible by inoculation; yet Laennec died of consumption, 
and Alibert and Biett of cancer." 

This writer also adduces two cases of men of robust constitution and 
amply developed chest, who became tuberculous after cohabiting with 
consumptive females, and two others in which the disease appeared to be 
communicated, under similar circumstances, to males. Dr. M. Cormac 
denies that consumption is any more contagious than a fractured limb. Yet 
he saw mothers seized with phthisis after nursing consumptive sons and 
daughters, sisters after having waited on sisters, brothers after succouring 
brothers. We shall never forget a case of the sort which we once met with. 
A widow, fifty-five years of age, thin, active, hardy, the very type of tough- 
ness in constitution, had many years before lost her husband with phthisis, 
and was about to lose a daughter of seventeen with the same disease. A few 
hours before the girl died her head lay in such a position upon her mother's 
shoulder that the latter could not avoid inhaling her daughter's breath. 



i Br. and For. Med.-Cliir. Rev., Jan. 1859, p. 202. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 



153 



She described it as causing an acrid sensation in her throat and a taste 
which she was unable to get rid of. In about a fortnight she began to 
cough, soon afterwards had haemoptysis, and within six months died of 
advanced consumption of the lungs. This may have been a coincidence, 
and so may the death by phthisis of the first two resident physicians of the 
Brompton Hospital for consumption, and the seven cases referred to in this 
connection by Dr. Leared. 1 It maybe that all such instances are explicable 
upon the ground that the individuals attacked would have been so at any 
rate ; for, certainly, the liability of most persons to this malady is greater 
than it is to any other cause of death. Nevertheless, the individual cases 
above referred to, and others which the experience of any physician who 
frequently treats the disease in private practice will furnish, are sufficient to 
justify Dr. Copland's rebuke, and to inculcate the duty of our preventing 
all unnecessarily close contact of the healthy with those who are in the 
advanced stages of consumption. 

The subject of the influence of pregnancy upon phthisis is naturally one 
^which interests every physician in his professional or personal relations. 
It is well known to be a commonly received opinion, that pregnancy sus- 
pends the progress of phthisis, an opinion which has been strongly con- 
troverted of late years, but quite as zealously defended. But in the defence 
the ground of the discussion is sometimes more adroitly than fairly shifted, 
by arguments referring to the phthisical constitution rather than to phthisis 
,itself. Thus, Montgomery 3 says : " My own experience would lead me to 
the conclusion that if a woman predisposed to phthisis, but in whom the 
disease has not actually become developed, prove pregnant, she is likely to 
be benefited thereby ; and I think I have seen life thus prolonged for years, 
in several instances." So, Dr. E. Warren 3 declares : "My object has been 
to show that pregnancy prevents the development of tubercles in those pre- 
disposed to phthisis ;" and Dr. Lawson remarks : " It is my conviction 
that in the tubercular predisposition, or even the precursory stage of 
phthisis, the occurrence of pregnancy under" favourable circumstances, and 
frequently repeated, so changes the vital actions as to delay, or entirely 
arrest the impending local deposits." On the other hand, Dr. Montgomery 
remarks, " If pregnancy takes place in a woman already actually in con- 
sumption, or if this disease supervene on pregnancy, the fatal issue is as 
likely to be accelerated as postponed, or, perhaps, even more so." Dr. 
Warren, after announcing his proposition as above, says that the objectors 
" have laboured to prove that pregnancy does not arrest phthisis itself, 
ivhen actually established" — a statement, therefore, which he does not 
formally contradict ; and Dr. Lawson, in regard to "this influence exercised 
by pregnancy over the progress of tubercles after they are deposited," 
expresses the opinion that if the tubercles are recent, few, and crude, and 
the strength and digestion of the patient good, the puerperal state [? preg- 
nancy] may retard the progress of the local disease ; but on the other 
hand, if the deposits are extensive and softened, the influence of gestation 
will almost inevitably prove injurious. 

Now, the first proposition, defended by the writers just quoted, will 
appear, upon a moment's consideration, to have little or no bearing upon ■ 
the question to be decided. Their assertions and their arguments amount 
to this, merely, that & predisposition to phthisis is not converted by preg- 

1 Med. Times and Gaz., Oct. 1856, p. 362. 

2 Signs and Symptoms of Pregnancy, 2d ed., p. 46. 

3 Prize Essay, p. 38. 



t 



154 Revieyv^s. [July 

nancy into consumption. But in what does a predisposition to phthisis 
consist ? Is there a single infallible sign of the mere imminence of the 
disease ? Do we not constantly meet with persons who appear to possess 
all the physical characteristics of the phthisical constitution, and who, 
yet, for many years, or altogether, escape the disease ? If females of this 
description bear children without suffering from tubercles, it merely proves 
their diathesis to be less decided than it seemed. The second proposition, 
in fact, yields the whole question. All of the writers referred to admit, or 
do not venture'to deny, that actual tuberculosis of the lungs is not retarded 
or favourably modified by pregnancy. Dr. Lawson does, indeed, say that 
if the tubercular deposit is limited and quiescent, and the general symptoms 
slight, pregnancy may retard the progress of consumption. But it is plain 
that those very conditions insure a slow progress of the disease indepen- 
dently of pregnancy. 

The well-known contributions of Grisolle and Dubreuilh to a positive 
basis of knowledge upon this subject, are opposed to the general conclusions 
of our author. The former of these gentlemen has recorded thirty-five, 
and the latter thirteen cases suitable for the solution of the question in 
hand. Now, if the evidence furnished by these cases were indefinite or 
ambiguous, they might be set aside ; but so far from being of this 
character, they all, without a single exception, agree in proving that preg- 
nancy does not suspend the progress of consumption. 1 Even more, they 
show that it does not modify materially the principal symptoms of the dis- 
ease. It also appears, from the cases above referred to, that, while occa- 
sionally phthisis may suddenly declare itself, or else rapidly grow worse, 
after delivery, as it does during the convalescence from various acute dis- 
eases, yet in by far the greater number the disease pursues its regular course, 
and in half of those who were delivered during the first or at the beginning 
of the second stage of the disease, the symptoms underwent a decided im- 
provement. Dr. Lawson remarks on these conclusions of Grisolle that it 
is " utterly inconceivable" that pregnancy should hasten, but parturition 
restrain or arrest the progress of phthisis. We beg leave to remark, how- 
ever, that the statement of Grisolle is not one of opinion, but of fact, and 
that if le vrai n'est pas toujours le vraisemblable, so le vraisemblable n'est 
pas toujours le vrai. 

A somewhat distinctive feature in Dr. Lawson's treatise consists in his 
ascribing to phthisis, and therefore in his introducing into its history cer- 
tain preliminary and, as we may say, premonitory indications of a tendency 
to it, and, also, of its approach. The former he styles the tuberculous 
constitution, objecting to the term diathesis, as being used to designate not 
a morbid condition, but a mere tendency to disease. We greatly err if the 
definitions are exact. The former term, constitution, is never applied to a 
morbid condition, while diathesis invariably includes the idea of such a state, 
actual or potential. Now this "constitution" is manifested, we are told, 
in tangible modifications of structure or function which indicate a departure 
from the physiological type. As the author passes them in review, how- 
ever, they mock the mental apprehension like dissolving pictures. We are 
assured, in as many words, " that there are no certain and infallible external 
indications of the tuberculous constitution." The tubercular dyspepsia of 
Philip, and Todd, and Bennett is proved to be a phantom evoked for 
theoretical uses. It might have been added that the acid dyspepsia which 



1 Bull, de l'Acad. de Med., xvii. 14. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 155 

plays so important a part in the last named gentleman's hypothesis, and 
which has some acceptance in Scotland and Germany, seems to be a natural 
consequence of oaten food in the one case, and of that " greasy and sour" 
cookery in the other, which has been so deservedly vituperated by travellers. 

The impaired power of expansion of the chest and lungs, which has been 
naively suggested to explain the deposit of tubercle, evidently depends upon 
loss of power in the respiratory muscles ; and when it shall have been 
shown that emaciation can advance so far as to occasion this debility with- 
out tubercles having been deposited in the lungs, the hypothesis will become 
more worthy of serious discussion. The attenuated state of the bloodvessels 
is said to favour the exudation of tubercle ; but again it must be asked 
which of the two precedes the other ? The nervous system in the tubercu- 
lous constitution, we are told, possesses an average degree of tonicity below 
the healthy standard. Here it seems probable that the strumous diathesis 
in the light-haired races has alone been kept in view ; for assuredly in the 
dark and in the negro races no such peculiarity exists. We cannot, there- 
fore, even upon the author's own exposition of the subject, agree that these 
and one or two minor " vices of the constitution may be safely regarded as 
an accurate measure of the predisposition" to consumption. We are, in- 
deed, at a loss to comprehend how he can regard them, even when united, 
as anything more than indications of a slightly greater probability that 
consumption may supervene than that it will not do so. The same may be 
said, moreover, of all kinds and degrees of impaired vigour, except such as 
depend upon diseases specifically antagonistic to phthisis. 

The phenomena indicative of the approach of phthisis are included by 
Dr. Lawson under the head, " The Precursory Stage of Phthisis, or Tu- 
berculoid Condition." It is said to be " characterized by decided morbid 
action, and yet is anterior to the deposit of tubercles." (p. 28.) Elsewhere 
it is distinguished from the diathesis (which term, as we 'have seen, the au- 
thor uses to denote a mere predisposition, which may never become de- 
veloped into disease), as being " the beginning of a positive morbid action, 
which, if not arrested, surely and steadily progresses to the deposit of tu- 
bercles." (p. 315.) In this stage, it is said, "we observe a more marked 
departure from the physiological state than belongs to the mere constitu- 
tional predisposition ; thus, the system loses weight, the strength diminishes, 
the secretions become still more variable, and calorification and innervation 
sink below the natural standard." These various phenomena our author 
illustrates in detail ; but, after carefully examining what he has written, 
. and finding that in a large number of cases "they pass unnoticed;" that 
"dyspepsia is not generally present;" and "that irregular chills with 
slight febricula" are asserted, without any proof whatever, to occur before 
any deposits in the lungs exist ; we remain very sceptical concerning their 
reality as antecedents of tuberculization. Undoubtedly, if tubercular deposits 
in the lungs depend upon constitutional causes, they may be preceded by 
special cachectic symptoms, and it rests with observation to declare what is 
the character of those phenomena. Now, neither Morton, Laennec, Louis, 
Stokes, Walshe, nor any one recognized as authority in such matters, 
whether among English, Continental, or American physicians, ever dis- 
cerned such a state, still less attempted to describe it. 1 Its first appearance 

1 We should, perhaps, except M. Fournet, whose principal work (Recherches 
cUniques, &c, et sur la premiere Periode de la Phthisie pidmonaire, Paris, 1839) con- 
tains many of the details now given by Dr. Lawson respecting this mythical stage 
of phthisis. Its conclusions have generally been regarded as not proven. See a 



156 



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[July 



in English, we believe, was in the Prize Essay of Dr. Howard Payne Cot- 
ton, which, like too many other essays of the same class, suggests that the 
competition for the prize must have been very limited, indeed. This author 
opens a chapter with the startling announcement that "prior to the ap- 
pearance of tubercle, phthisis is very frequently within the control of reme- 
dial measures" 1 (p. 26), and afterwards describes the symptoms preceding 
the formation of tubercles, as progressive loss of vigour, pallid or sallow 
complexion, anxious but animated expression, sharpened features, hurried 
movements, irritable and capricious disposition ; uncertain appetite, imper- 
fect digestion, passive diarrhoea ; slow, small, and excitable pulse ; restless 
and unrefreshing sleep, with occasional perspirations ; and invariable loss 
of weight. Dr. J. C. Hall treats of a "period preceding the deposit of tu- 
bercle," in terms evidently borrowed from Dr. Cotton. Dr. Edward Smith 
has his notion also of a " pre-tubercular stage which is capable of easy 
demonstration," but ignores this long list of portentous symptoms, and 
especially those of a dyspeptic nature, and makes it to consist in a "dimi- 
nished vital capacity of the lungs," which appears to mean a diminished 
power of expansion, and is attributed to exhausting causes of some kind 
not specified. 3 A very rational account of this subject is contained in the 
Lectures of Dr. James E. Pollock, 3 who states that the earliest symptom 
of tubercular disease is wasting,, which precedes cough, haemoptysis, and all 
the physical signs, and is earlier in point of time than hectic. After 
wasting, debility soon supervenes, and then some hectic fever, and occasion- 
ally purpura and mucous hemorrhages. The most extraordinary pre- 
tubercular stage is that described by Dr. John Hogg. 4 The array of symp- 
toms ascribed to it above is one of mere trifles compared with that which 
he depicts. Our space forbids even a complete summary of them ; but, 
besides a leaden, greenish, transparent, or pimply skin, a countenance that 
"acquires an air of mild benevolence," a red furred tongue, thirst, fetid 
breath, confined or loose bowels, emaciation, with thin, skinny, cold, blue, 
lumpy, and bulbous fingers, we have emaciation rendering the joints pro- 
minent, the once capacious chest becoming flat, the breasts in females 
shrinking away, and the clavicles projecting ; "the faculties of the mind 
falter, and are incapable of any exertion ;" a presentiment of evil is experi- 
enced, and an occasional hectic flush is observed on the cheek. Our expe- 
rienced readers will imagine that we have here a picture of consumption far 
advanced, but they are mistaken. Dr. Hogg says, " The lungs even now 
probably present obstacles, by their atrophy and shrinking, to the free cir- 
culation of the blood through them, causing an increased effort of the heart 
to propel it, the tuberculous deposit not having yet commenced." (p. 31.) 
According to this author, the debility still goes on increasing, and is at- 
tended with headache, stitch in the side, shortness of breath and a short, 
hacking cough, and, in females, with leucorrhcea and amenorrhoea. There 
is now dulness under the clavicles, generally the left, and the respiratory 
sounds at the same points are rough. But " up to this time there has been 
no deposit of tubercle, so far as we can discover" (p. 3f ) ; while " in more 

criticism in the Brit, and For. Med. Rev., ix. 323. In a paper on "The Curable 
Stage of Phthisis" (Edinb. Med. Jour., ii. p. 683), Dr. Edward Smith claims that 
such a stage exists, and denominates it the " pretubercular stage," but offers no 
tangible proof of its reality. 

1 The Nature, &c, of Consumption, London, 1852. 

2 Lancet, Nov. 1856, p. 489, 524. 3 Lancet, Aug. 1856, p. 154. 
4 Practical Observations on the Prevention of Consumption, London, 1860. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 



15T 



marked cases, where tuberculization is nearer at hand, the inspiration is 
puerile, bronchial, or even amphoric, according to the intensity of the pre- 
disposition to the disease, while expiration is short and indistinct." With 
these signs, that is, all that have been described, some authors, says Dr. EL, 
"Laennec, Louis, and others consider tuberculization to have commenced." 
We should think they did. But, we are told, " Louis goes so far as to say 
that ' tuberculization commences from six months to two years before its 
announcement by cough or any obvious pectoral symptoms.'" We are not 
able to find any such statement made by Louis ; on the contrary, he de- 
clares that "in the majority of cases coughing begins without any assign- 
able cause, in the midst of perfect health." (Op. cit., p. 526.) 

Is Dr. Lawson prepared to accept these descriptions as representing the 
precursory signs of phthisis, and if so, which of them ? They are mutually 
contradictory, and comprise all grades of disease from the nearly absolute 
negation of symptoms by Dr. E. Smith, up to the numerous and grave 
disasters described by Dr. Hogg, and which really appertain not merely to 
the stage of crude tubercles, but to that of softening also. Under the title 
"First Stage," Dr. Copland enumerates the greater part of the less grave 
symptoms which have been above referred to; but he says : " The lungs at 
this period contain a greater or less amount of tubercular deposit in what 
has been called a state of crudity" (p. 14). This is the opinion universally 
held by all who are conversant with the subject, except the writers above 
named and a few others of inferior position, and it is also that which we 
entertain ourselves ; but as we know of no greater pleasure than an in- 
crease in knowledge of the laws of disease and of the means of curing it, 
we should hail with heartfelt satisfaction any novel view or method, pro- 
vided only it were based on truth. Thus far we think that the statements 
in question have been shown to be inconsistent with truth ; and, therefore, 
when we find Dr. L. adding to the characters already enumerated, signs 
revealed by inspection, percussion, and auscultation, yet perfectly equal 
upon the two sides of the chest, signs, therefore, which can depend only 
upon the debility of the patient, and possibly on a partial but symmetrical 
loss of flesh, we feel persuaded that he has allowed himself to be led astray 
from the real towards the ideal by a desire to over-refine in the art of diag- 
nosis which he has so successfully cultivated. 

In the critical remarks that have been made, it is not our intention to 
imply that no phenomena exist which may justly be suspected of indicat- 
ing the imminence of consumption. In this disease, as in most others, the 
local lesion is the result of a previous derangement of the nutritive func- 
tions ; but we look in vain for proof of the special character of that de- 
rangement. Before the deposit of tubercle reveals itself by physical signs, 
the health must be deranged, for these signs are indicative only of a certain 
accumulation of the morbid matter ; and it must not be forgotten that the 
tubercular deposit, in some cases in which its recognition is preceded by 
general symptoms of impaired health, may not occupy the apex of the 
lung, but a more central part of the organ where its existence is not 
betrayed by any physical signs. Yet in not a few cases the evidence of 
impaired health is either wanting altogether or is quite equivocal, as the 
preceding statements are intended to show. We are disposed to believe 
that the symptoms which precede the material evidence of tuberculization 
are very far from uniform, and depend for their special character upon the 
age, sex, constitution, temperament, and various other peculiarities of the 
individual patient, among which the habitual want of vigour of some par- 



158 



Reviews. 



ticular function holds a prominent place. The person of weak digestion 
may suffer from dyspepsia, and the nervous, from an increased excitability, 
including chilliness and feverishness ; some may experience shortness of 
breath, and others neuralgic pains in the chest, but the only condition 
common to the greatest number on the approach of chronic phthisis is loss 
of flesh and strength. The semeiological value of this symptom, it need 
scarcely be added, depends altogether upon the absence of every other cause, 
and they are legion, which can produce the same effect. Besides which, as 
Dr. Lawson remarks in another place, there are frequent exceptions to the 
rule, and Louis found only one-half of the cases exhibiting emaciation from 
the beginning. A similar fact has been observed by Fournet, Walshe, and 
others. For ourselves we should regard dry cough as far more frequently 
thau emaciation, the earliest symptom of consumption. 

We have not, in the preceding review, taken any notice of a paper by M. 
H. Bourdon, and which was really in advance of all that have been cited, 1 
because this writer does not claim that the symptoms which he describes 
are independent of tuberculization, although they may precede the physical 
signs of that condition. The paper of Dr. B. is of sufficient importance 
for us to transcribe its conclusions, which are as follows : — 

" When disorders of the digestive function are observed, and particularly 
chronic dyspepsia, or vomiting without evident cause and which is intractable 
to all treatment ; 

" Or when, although there is neither hepatitis nor heart disease the liver is 
enlarged and tender ; 

" When these phenomena occur alone or during such a disease as chlorosis, 
typhoid fever, or measles, phthisis is to be suspected. 

" " Therefore the medical history of the patient must be learned, and his re- 
spiratory apparatus must be closely scrutinized for any trace of commencing 
tuberculization that may exist ; and if, notwithstanding the absence of every 
characteristic stethoscopic sign, there should be a daily exacerbation of fever 
and perspiration at night, emaciation, and debility, the presumption in favour of 
phthisis would be very great indeed, and prudence would require that its exist- 
ence should be regarded as certain." 

Among the symptoms of the precursory stage of phthisis enlargement 
of the m ucous follicles of the pharynx occupies a prominent place in Dr. 
Lawson's description. We supposed that this condition of the throat had 
ceased to be spoken of as an essential phenomenon or even a frequent com- 
plication of phthisis, except by writers who address themselves to the fears 
of invalids rather than to physicians made familiar with disease by 
personal observation and an enlightened literary culture. The prominence 
accorded to it, therefore, by a writer so well fortified by experience and 
study as Dr. L., induced us to revise our judgment and endeavour to rectify 
in it whatever the review might prove to be erroneous. Dr. Lawson admits 
that " systematic writers have dwelt but little on the condition of the 
pharynx in the early stage of tuberculosis," but adds, "in the more advanced 
stages of tubercular disease the affection of the throat has been fully 
described by nearly all writers." (p. 319.) These remarks imply that 
the condition of the pharynx has not usually been studied, but that 
where it has been examined the lesion in question was detected. Upon 
this inexplicable statement we need only remark, after Louis, that in one 
hundred and twenty cases of death by phthisis, ulcers of the pharynx were 
found only four times ; that they were numerous, small, and equally dis- 



Actes de la Soc. Med. des Hopitaux de Paris, 1852. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 



159 



seminated over the whole membrane ; and that during life they occasioned 
no symptoms whatever. 1 This last clause meets the objection that atten- 
tion had not perhaps been paid to the symptoms which the state of the 
throat would occasion. 

If it is suggested that in these cases follicular disease and its local 
consequences may have disappeared before death, we reply by quoting 
Dr. Lawson, who says, "I am fully satisfied that, in a large majority of 
cases passing into consumption, the pharyngo-laryngeal structures become 
early and permanently diseased." " The form of morbid action," says 
Dr. L., "to which the tonsils are subject, appears to be of a suppurative 
character, and, as believed by Dr. Green, also tubercular." These glands 
are said to be early enlarged, but this condition is not permanent; "on the 
contrary, the tendency is to a suppurative or even ulcerative action, with, 
ultimately, absorption or destruction of almost the entire glands." If Dr. 
Lawson makes this statement upon his own authority we must be content 
to believe that his experience has been altogether peculiar, for there is not 
a single pathological anatomist who describes anything of the kind as 
characterizing the tubercular diathesis or disease. On the contrary, no fact 
is more familiar than that in persons of a strumous constitution enlarge- 
ment of the tonsils tends to become permanent with induration. 

Equally singular is the opinion of Dr. Lawson, that the cheese-like sub- 
stance observed in the tonsils, and which occasionally becomes cretified, is of 
a tuberculous character. Yet he quotes Hofle, Wedl, and even Rokitansky 
in support of the opinion. But Hofle and Wedl say of these yellowish- 
white, oval, and fetid masses that " they are hawked up by both healthy 
and diseased individuals," and " have heretofore been frequently regarded 
as crude tubercles." Wedl adds that upon microscopic examination they 
are found to consist merely of buccal epithelium, pus-corpuscles, oil-drops, 
and solid amorphous fat, 3 Foerster speaks of them as dried mucus and 
pus which sometimes undergo calcification f and Lebert describes their 
cheesy consistence and fetid smell, and their conversion into bodies of almost 
stony hardness " which, when rejected, are easily mistaken for tubercles." 4 
But Dr. Lawson asserts : " Rokitansky calls the substance 1 tubercular or 
cheesy plugs,' and there is reason to believe that it is of a tuberculous 
character." This statement we are obliged to rectify: The words of the 
Yiennese anatomist are these : " The purulent secretion not unfrequently 
becomes inspissated, so as to form tubercular cheesy plugs, or even chalky 
concretions," the word tubercular evidently referring to the form and not to 
the nature of these bodies. 5 Neither in the first nor in the last edition of 
his treatise does he so much as mention the pharynx among the organs in 
which tubercles may be deposited, and in the second work his only allusion 
to the pharynx, in this connection, is when he says, "scarcely ever does 
tuberculosis spread from the larynx into the pharynx." 3 

As already stated, Dr. Lawson avers that in " a large majority of cases 
passing into consumption, the pharyngo-laryngeal structures become early 
and permanently diseased" (p. 319); but subsequently his opinion is ex- 
pressed in very different terms; for he says (p. 321), the constancy with 
which the throat affection is manifested shows its intimate relation to 
tuberculosis " at least in a certain number of cases." In the next sentence 
he speaks of its occurring as one of the earliest signs in "a large class 



» Op. cit., pp. 67, 68. 

3 Pathol. Anatoniie, pp. 8 and 12. 

5 Syd. Soc. ed., ii. 7. 



2 Syd. Soc. ed., p. 325. 

4 Handbuch d. prakt. Med., ii. 215. 

6 Vol. i. p. 308. 



160 



Reviews. 



[July 



of examples." These varying terms present an idea of the frequency of 
its occurrence which is very far from precise. Further, the degree of its 
evil influence does not seem to be very definitely settled in the author's 
mind ; for, while he "will not go so far as to maintain it to be a cause of 
the local deposits" in the lungs, still he thinks it "by no means certain 
that this condition is not a primary local lesion, incident to the tubercu- 
lous state," which "at least hastens the pulmonary affection." But if it 
is not an ordinary antecedent of phthisis, or if phthisis is not its ordinary 
sequence, this statement loses all weight and force. That there is no such 
relation between the two affections we have already given authoritative 
reasons for believing ; but more remain behind in the statements of the 
most experienced observers of disease and the most accomplished patholo- 
gical anatomists. 

In 1853 the late Dr. Todd fully described the symptoms of the throat dis- 
ease and its treatment, and even admitted, what is denied by others, that it 
"often extends to the larynx and trachea, and sometimes into one or more 
of the bronchial tubes." He does not say one word of its relations to 
phthisis either as cause or effect, but alleges, on the other hand, that it "is 
very common in men of gouty diathesis, and in women of a relaxed habit 
who do not take proper care of their health." 1 Now, gout, it is well 
known, is antagonistic to tubercle. 

Lebert, after describing the affection as "angina gutturalis" and "angina 
chronica," remarks that it "sometimes gets well spontaneously, sometimes 
lasts for months or years, and either gradually disappears, or, without 
occasioning any danger, may never be completely cured. Not unfrequently 
it is associated with chronic diseases of the skin." 2 Grisolle remarks : " This 
disease is not only rebellious, but may induce various annoyances ; thus it 
may ultimately produce a complete change in the voice ; but it never is 
fatal, and Dr. Green to the contrary notwithstanding, it can never undergo 
any organic degeneration." 3 Dr. Flint, whose authority as a pathologist 
is only surpassed by his character for probity, says : "Having had oppor- 
tunities of observing numerous cases in which chronic pharyngitis has 
persisted for years, I am satisfied that so far from the affection tending to 
tuberculosis, it is rather rare for the latter disease to become developed in 
this class of patients ; and, in fact, I have been led by experience to regard 
the former as militating against the presumption of the existence of the 
latter."* M. De Mussy, who mildly expresses his astonishment at some of 
the horrible results attributed by certain writers to follicular disease of the 
pharynx, asserts, nevertheless, that it frequently complicates phthisis. But 
he has so little notion of its being a stage or a cause of tubercular con- 
sumption, that in his article upon its pathogenesis the word tubercle does 
not even occur, and the affection itself is regarded as a manifestation of 
the herpetic diathesis. 5 One of the Brompton Hospital physicians, Dr. 
Edward Smith, has written an article entitled "Remarks on the Throat, 
in Cases of Chronic Phthisis and Chronic Bronchitis," which shows that 
he made the disease a subject for special investigation; yet he concludes 
that enlargement of the pharyngeal follicles is much more common in 
chronic bronchitis than in phthisis, while the condition most characteristic 
of the latter disease is paleness of the mucous membrane of the throat. 6 

1 Times and Gaz., Feb. 1853, p. 209. 2 Handbuch der prakt. Med., ii. 210. 

3 Pathol. Interne, 7eme ed. i. 258. 

4 Diseases of the Respiratory Organs, p. 497. 

5 Traite de l'Angine Glanduleuse, p. 95. 

6 Liverpool Med.-Chir. Jour. July, 1857, p. 189. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 



161 



Anxious as we are to avoid even the appearance of injustice, we subjoin 
the testimony of another Brompton physician, Dr. Alison, of whose work 
we have spoken in terms of praise. After referring to certain tracheal 
and laryngeal sounds indicative of the first stage of consumption, he 
remarks : " When, on the other hand, the fauces have been long congested, 
when there is ulceration, or when there are signs of recent inflammation, 
when the urgent symptoms of laryngitis and croup are pressing, it is little 
likely that phthisis is present." (p. 116.) In another place he says : "The 
pharynx in the first stage of phthisis occasionally becomes the seat of 
physical alteration. The mucous membrane is roughened as well as red- 
dened. The follicles become enlarged, and sometimes, but rarely, the seat 
of minute ulceration." (p. 122.) In the second stage an analogous condi- 
tion is stated to exist in " a large proportion of examples," (p. 164,) and in 
the third stage also " in an aggravated form." (p. 267.) But, in a sub- 
sequent chapter, this author says : — 

" If, when the patient is only slightly disturbed in his health, and when the 
thoracic physical signs of phthisis are ill marked, the gums present a fine red 
border along the edge of union with the teeth, and the fauces are only very 
slightly congested, or perfectly healthy, the probability of pulmonary disease in 
an incipient form being the primary complaint is considerable. If, on the other 
hand, the fauces be highly vascular, granular, or granulous, the posterior wall 
of the pharynx be rough, tuberculated, and covered here and there with thick 
green mucus, or the tonsils be irritable, large, and projecting, and associated 
with enlarged cervical glands on the exterior of the neck, and the voice be more 
or less hoarse or nasal, and no decisive physical signs of phthisis are to be ob- 
tained by auscultation or percussion, it is highly probable that the primary and 
chief disease is within sight, and that the thoracic symptoms and signs are only 
secondary, and very likely to pass off upon the cure of the morbid conditions 
above referred to." (p. 354.) 

We have been particular to quote these passages, because, like those of 
Dr. Lawson, they are more or less at variance with the statements of other 
authoritative writers on phthisis, and more especially because they are in 
direct opposition to those of Dr. E. Smith, who studied the disease in the 
very same institution as Dr. Alison, so that the discrepancies are not expli- 
cable by any presumed difference of climate, race, &c. But the statements 
of Dr. A. are so far from being harmonious in support of the idea that 
granular pharyngitis has any direct relation to phthisis, that he actually 
adduces the existence of this condition as denoting freedom from pulmonary 
tuberculosis, and antithetically with the declaration that a perfectly healthy 
throat, in connection with a red line on the gums, renders the probability 
of pulmonary disease considerable. 

We have said enough, and perhaps more than enough, to show that the 
frequency, nature, phenomena, and tendency of follicular pharyngitis have 
been misapprehended by the author of the work now specially under notice, 
and above all that it has no connection whatever, except an accidental one, 
with tubercular consumption. Our own observation accords perfectly with 
that of the gentlemen whose testimony has been quoted. For twenty-five 
years that we have studied diseases of the respiratory apparatus with pecu- 
liar care in public and in private practice, both before and since the attempt 
was first made in this country to excite attention within the profession and 
alarm beyond it by styling an innocent but annoying throat affection 
■ ' tubercular," we have never yet witnessed any relation between tubercular 
phthisis and the follicular disease in question other than one of mere coin- 
cidence in exceptional cases. In the former we have sometimes found the 
No. LXXXIIL— July 1861. 11 



162 



Reviews. 



[July 



throat anemic, wasted, and occasionally dry, but very rarely studded with 
enlarged follicles ; in the latter the chest symptoms of any sort have been 
usually slight, and we can scarcely recall an instance in which it preceded 
the development of consumption. 

We have no wish to conceal the fact that sundry writers assert the more 
or less intimate relations of follicular pharyngitis and phthisis. They are, 
in part, however, such as seem to address more frequently a popular than 
a professional audience in the little books which they usually publish. 
Others appear to have compiled indifferently from sources of very unequal 
authenticity and authority, and to have filled their pages with contradictions 
to which their own inexperience blinded them. We are acquainted with 
no other example than that of the work before us of so much ability and 
so many proofs of candour in the treatment of the subject generally, asso- 
ciated with what we are bound to pronounce an incorrect description and 
an unfounded and dangerous doctrine. 

Dr. Lawson, in treating of hemorrhage as a symptom in phthisis, does 
not allude to the possibility of its occurring as a result of heart disease, 
or from a suppression of the catamenial, hsemorrhoidal, or some other 
habitual discharge. He states, also, his opinion " that copious hemor- 
rhage may occur anterior to the deposit of tubercles," (p. 325,) assigning, 
however, the untenable reason that no physical signs of tuberculous deposit 
may precede the discharge. In another place, he says, "I am fully persuaded 
that pulmonary hemorrhage, in a vast majority of cases, is the result of 
tubercular deposits." (p. 336.) That haemoptysis sometimes, though very 
rarely in the male, is not followed by active phthisis, must be admitted ; 
but considering the very great frequency with which the latter disease is 
ushered in by the symptom in question, and the fact that very limited 
tubercular deposits may exist for a long time and even undergo such cure 
as they are susceptible of, and all the while be undetected by physical 
methods of examination, it is more probable that tubercles exist than that 
they do not whenever hemorrhage from the lungs takes place without any 
other tangible cause for its occurrence. Nothing is said by Dr. L. of the 
age at which haemoptysis occurs. Rilliet and Barthez saw no case of it in 
a child under seven years of age ; but one is reported of a child about as 
many weeks old who died from this accident in the Bellevue Hospital. 1 
Its lungs contained scattered miliary tubercles, but no cavities. 

The subject of physical signs in phthisis is one which seems to have 
been almost exhausted by the numerous skilful physicians who have devoted 
themselves to its elucidation, and the indispensable aid which it renders is 
familiar even to the youngest and least practiced in the profession. It 
sounds strangely, therefore, when Dr. Copland tells us that physical diag- 
nosis has been "paraded, over-estimated, and lauded" (p. 3), speaks of 
"the examination of the bared chest for the grand coup of fussy diagnosis" 
(p. 62), or thus: " Whilst a murmur, a bruit, a rale, a rhonchus, and every 
sound for which a term could be coined, and their various grades, cadences, 
&c, were heard, or were feigned to be heard, the conditions of the vital 
powers and functions were entirely neglected." (p. 262.) Probably, if we 
were compelled to depend for our guidance in diagnosis and treatment 
either upon physical signs alone, or exclusively upon whatever was known 
before Auenbrugger and Laennec enlightened the dark region of pulmonary 
pathology, we should unhesitatingly trust ourselves to the former; because, 



1 New York Journ. of Med., March, 1S57, p. 233. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 163 

while its field is narrow its phenomena are definite and precise, and supply 
us with a foundation for diagnosis and practice without which our thera- 
peutics of the early stage of the disease would not be more secure than 
castles built on air. Few writers of real eminence among those who have 
treated of phthisis are opeli to the charge which Dr. Copland makes, and 
few especially of those who have appeared in the latter half of that almost 
one-third of a century during which the learned author was compiling his 
valuable work. Dr. Lawson is not certainly of the number, but is one 
of those who think it just as important to be accurate in physical as in 
functional semeiology, but who regard the former as much more attainable 
than the latter. His account of both is fuller than that given by previous 
writers, and if at times we differ from and criticize him, it is because we 
think that the materials of his work are stout enough to bear a little 
trimming of their apparent superfluities and excrescences. 

It is unnecessary to pass in review every part of his elaborate description ; 
we shall only notice here and there a few points which suggest remark. 
Thus, jerking or wavy respiration is stated not to be a reliable sign of 
phthisis independently of dulness, dry crackling, or localized feeble or harsh 
respiration, because it occurs in various other conditions unconnected with 
phthisis. Certainly, if those signs are present, the one in question need 
not be regarded ; but it is in their absence that jerking respiration becomes 
valuable, provided that no other sufficient cause of imperfect expansion of 
the lung exists. Such we have always found it. M. Bourgade, who has 
carefully studied the subject, arrives at the same conclusion, which he thus 
expresses : " If a patient presents the general symptoms of commencing 
phthisis and jerking respiration, the existence of the disease is rendered 
certain." 1 

Dr. Alison presents us with a very interesting rationale of bronchophony. 
It was the opinion of Laennec, and is so of auscultators generally, that 
this is a sign of pulmonary solidification when heard over the lung itself, 
whereas Skoda leaves this element out of view, and refers the phenomena 
to consonance of aerial vibrations in the larynx and the bronchia. But 
Dr. Alison shows that while a feebly vibrating column of air will generate 
a sound which can be heard better through the normal than through the 
solidified lung tissue, yet one which is capable of throwing the latter into 
vibration will, by its means, generate a louder sound than the normal 
tissue, and hence that consonance and increased conducting power are both 
necessary to explain bronchophony. Yet he agrees with Skoda that to the 
former the most of the result is to be attributed. Dr. Alison observes that 
a distorted and deformed shape of the chest is not apt to be connected with 
phthisis, and in this, we think, other physicians will agree with him. In 
an interesting chapter on thoracic arterial murmurs in phthisis, he de- 
scribes the frequent occurrence of a blowing sound in the arteries near the 
seat of tubercular deposits at the apex of the lung, and ascribes it to 
pressure. Doubtless this cause may sometimes be operative, but tubercular 
anaemia is less considered than it deserves to be in this connection. So in 
attributing the increased loudness of the heart sounds in phthisis to the 
increased activity of the organ and to the destruction of the lung, he omits 
the element of thinning of the walls of the heart, and that of the watery 
condition of the blood. A phenomenon of some importance is that the 
vocal resonance is occasionally louder over the healthy than over the tuber- 



* Archives Gen., Nov. 1858, p. 531. 



164 



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culated lung. This may depend upon direct obstruction of the bronchia of 
the diseased organ, or its imperfect expansion in consequence of contraction 
of the thoracic walls. To all such cases, and others in which different de- 
grees of the same phenomenon are to be studied comparatively on the two 
sides of the chest, the differential stethoscope is" admirably adapted. 

Dr. Lawson calls attention to the fact that tubercular ulceration of the 
bowels and constipation may exist together. A remarkable example of 
this curious circumstance is reported by Dr. Fuller. 1 We have observed 
the same thing in typhoid fever. In connection with oedema of the feet in 
the third stage of the disease, Dr. L. might have noticed that form of it 
which is confined to one extremity and is caused by obliteration of the 
veins. Cases of the affection are reported by Dr. Cursham. 3 The general 
summary of the phenomena of chronic phthisis is very clearly, and, with 
certain exceptions already noticed, very accurately presented. The most 
characteristic of the early signs are stated to be emaciation, cough, and 
haemoptysis; yet we are warned against the risk of basing a judgment 
upon any small number of symptoms, and two cases are adduced as illus- 
trations, in one of which there was no cough and in the other no emacia- 
tion. Of the early physical signs, Dr. L., in common with diagnosticians 
generally, regards dry crackling as the positive representative of consoli- 
dated tubercle, but believes that another, which he terms "tubercular cre- 
pitus," is the true sign of tuberculoid fluid exudation. It is described as a 
little finer and drier than ordinary pneumonic crepitus, and is stated to 
have been heard when no other sign was present, and also upon the limits 
of tubercular consolidation. 

Under the general title of Inflammatory Phthisis, Dr. Lawson describes 
several forms of disease, to which the application of this name is, at least, 
of doubtful propriety. They merely comprise cases in which pneumonia, 
bronchitis, or pleurisy appear to favour the degeneration, if not the 
development of tubercle. The first variety, " Parenchymatous or Plastic 
Pneumonic Phthisis," is described as " ordinary pneumonia with plastic 
exudations ultimately tending to tubercular deposits." "It is evident," the 
author adds, " that pulmonary inflammation often becomes the direct in- 
ducing cause of phthisis, and imparts to the whole course of the affection 
an inflammatory grade of action." We have already stated what we con- 
ceive to be the true relations of phthisis and pneumonia, and shall not 
describe them anew, but will only remind the reader that the cases in which 
tubercles even appear to be the result of pneumonic inflammation are ex- 
tremely rare, while in the greater number there are conclusive reasons for 
regarding the tubercles themselves as the primary affection. It cannot be 
denied that they very frequently occasion intercurrent pneumonia, which is 
neither dangerous itself, nor seriously mischievous in its action upon the 
greater number of cases in which it occurs. In regard to "Vesicular 
Pneumonic Phthisis," which is used as synonymous with " gray tubercles, 
gray semi-transparent granulations," &c, reasons have already been given 
for the doctrine, from which Dr. Lawson (following Andral's opinion) is 
one of the few dissentients, that these bodies are in no essential respect 
different from the tubercles of chronic consumption. Yet Dr. L. expressly 
refers to cases which have been of sufficient duration to allow of their 
"transformation into yellow tubercle," and he might have added that 
Laennec speaks of one in which even softening of the deposit took place 



1 Trans. Lond. Path. Soc, xi. 103. 



2 Med.-Chir. Trans., xliii. 377. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 



165 



within a month from the commencement of the attack. In a word, gray 
semi-transparent granulations constitute the proper anatomical character 
of nearly all cases of acute tuberculosis of the lungs, and their transforma- 
tion into yellow tubercle, and subsequent softening, depend solely upon 
whether the patient survives long enough for these changes to take place. 
The third variety of acute phthisis described by Dr. Lawson is the 
" Broncho-pneumonic," by which term he denotes the cases which super- 
vene on chronic bronchitis and broncho-pneumonia. Reasons have already 
been given for excluding these affections from the category of causes 
directly productive of phthisis, while we grant that in common with every 
debilitating agency, they may become the immediate forerunners of consump- 
tion in those who have a proclivity to the disease. But it is undeniable 
that in the majority of cases of acute phthisis, neither bronchitis nor pneu- 
monia has preceded the development of the symptoms peculiar to the 
tubercular affection. If anywhere they appear as antecedents of con- 
sumption, it is when they are themselves chronic and precede the chronic 
form of the organic disease. The same remark is applicable to what Dr. 
Lawson terms " Pleuritic Phthisis ;" indeed, this author admits that the 
agency of pleurisy in its production " must generally be incidental or in- 
direct." 

As this form of disease is not very fully presented by the author just 
named, nor as accurately as the present state of knowledge regarding it 
requires, we shall offer a brief sketch of the more recent and authoritative 
expositions of its forms and nature. Dr. Copland describes a " primary 
or rapid acute phthisis" and a "consecutively acute phthisis." The latter 
is only " an acute or actively developed state of the pre-existing chronic 
disease." The former he divides into two varieties: "that in which the 
more characteristic phenomena of phthisis are present in a remarkable or 
severe degree;" and "that in which these phenomena are nearly if not 
altogether absent; the disease being often mistaken for low, nervous, or 
typhoid fever." In both of these forms, Dr. C. admits the pre-existence 
of latent tubercular deposits, and Lebert states that, after death, old tuber- 
cles are found in the lungs and bronchial glands. The first named author 
enumerates, as occasional or exciting causes, eruptive fevers, various in- 
flammatory affections of the lungs, and severe physical exertion ; of these 
Lebert mentions measles only, and concludes that in the majority of cases 
the true occasional causes are unknown. 

The first accurate history of this affection based upon a sufficient number 
of cases was published by Waller, in 1845, 1 although it had previously been 
more or less accurately and fully described by Morton, Portal, Bayle, Laen- 
nec, Andral, and particularly Louis. He refers to two anatomical forms 
in which it occurs, the miliary and the infiltrated ; and, according to their 
course, he divides the cases into Typhoid, Catarrhal or Bronchial, Gastric, 
Intermittent, and that masked by Delirium Tremens. He regards the diag- 
nosis of the first mentioned form from typhoid fever as extremely difficult, 
since active delirium, disturbance of the respiration, copious sweats, the 
absence of abdominal symptoms, the character of the cutaneous eruptions, 
and even the enlargement of the spleen may be met with in either disease. 
Indeed the chief symptomatic distinction he finds in the less regular 
development of the symptoms in acute tuberculosis. In some cases he 
believed that the two affections co-existed ; and in others that the tubercu- 

1 Prager Vierteljahrsckrift, vi. 1. 



166 



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lous followed the typhoid affection. The catarrhal form owes its peculiari- 
ties to the accompanying congestion, oedema, or emphysema of the lungs. 
In one variety the attack is preceded for a few days by violent cough, or 
begins with a heavy chill and continued fever. The respiration is very 
hurried, laborious, and short, and the dyspnoea extreme ; the cough is 
violent and produces a copious expectoration of frothy, albuminous sputa, 
streaked with blood. Percussion is normal or tympanitic, and the rhonchi 
are those of bronchitis. The face is pallid and very anxious, the skin hot, 
pulse 130 — 150, the ankles cedematous, and the loss of flesh and strength 
rapid. After a few days the lips and hands and feet become cyanotic, and 
death by " paralysis of the lungs" takes place. Besides the evidences 
found of catarrh, oedema, and emphysema of both lungs, these organs 
contain numerous disseminated tubercles. In another variety the symp- 
toms are less intense and of longer duration, and are accompanied with 
tubercular infiltration. This anatomical condition renders it more possi- 
ble than in the other form, to recognize the state of the lung. The signs 
of a tubercular mass may, however, be due to a pre-existent and chronic 
deposit. In many cases vomiting and gastric pain are observed. The 
third form described by Waller, is the gastric, in which the symptoms just 
mentioned, with catarrh of the pharynx, and diarrhoea, precede and ac- 
company the typhoid or catarrhal states. The disease, according to this 
author, may wear the mask of intermittent fever at first, but finally merges 
into one or the other of the forms just named. It is asserted that the 
deposit of tubercles takes place so rapidly during the paroxysms as to 
allow its increase to be estimated from day to day. The commencement of 
the attack may also be masked by delirium tremens. It is stated by 
Waller that acute tubercular infiltration of the lung always presents the 
symptoms of pneumonia, and cannot be clearly distinguished from it. 
Rokitansky makes a similar statement. 1 

The most complete exposition of this affection which has yet been pub- 
lished is that of Lebert, 3 which is based upon no less than forty cases 
recorded by himself. He states that in more than one-third of the fatal 
cases, old tubercles were found at the apices of the lungs. The pulmonary 
tissue around the recent granulations was generally quite sound or only 
slightly congested ; but all grades of solidification were also observed. 
Twice the larynx was deeply ulcerated ; in one case the epiglottis being 
nearly destroyed. The follicles of the larynx were generally enlarged, but 
not tuberculous. Five times tubercles of the brain were found, and in the 
small intestine ulcers of the glands were present in one-third of the cases. 
This author presents a full description of the symptoms of the disease, but 
our limits will not permit us to do more than notice the forms which he 
has found it to assume. These are : 1. The Latent Form, or the Gastric 
Form of Waller. The symptoms are those of gastric fever, with rapid 
and extreme emaciation, but neither cough, dyspnoea, nor thoracic pain. 
The only physical signs are catarrhal rhonchi. The patient rapidly runs 
down and is apt to die suddenly. Three cases of the sort were observed by 
Lebert. 2. The Proper Tuberculous Form affects one-half of all the cases. 
In it the fever is intense, the debility extreme, the breath very short and 
quick, the cough harassing, the sputa sometimes bloody. Percussion affords 
no definite signs, and auscultation reveals sonorous, sibilant, and fine crepi- 
tant rhonchi, and perhaps some blowing at the summits. Diarrhoea, colic, 



1 Lehrbuch, 3d ed., iii. 301. 



2 Handbuch der prakt. Med., ii. 105. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 167 

meteorism, depend upon intestinal ulcers ; and vomiting, hardness of the 
abdomen, and ascites upon tubercular peritonitis. The fever has generally 
a typhoid type. 3. The Cerebral Form is next in frequency, although 
much less frequent than the last. Along with characteristic fever of a 
typhoid type are observed disorder of the senses, paralysis, spasms, and, in 
addition, the chest symptoms already referred to. 4. The Masked Form is 
rare, and is characterized by the prominence of the symptoms of some 
other disease which conceal that of the lungs. Delirium tremens or in- 
termittent fever, as Waller states, or laryngitis, pneumonia, or pericarditis, 
may hide the more important affection. The diagnosis of the disease is 
confessed by all to be extremely difficult in many cases, and especially, in 
one of its forms, from typhoid fever. This fact must render us slow in ac- 
cepting as cases of cure some which appear to be so. The possibility of 
cure is, however, established both by Waller and Lebert. The former 
affirms that the fact is indubitable, and the latter witnessed recovery in six 
cases. In four persons who afterwards died of other diseases, the evident 
traces were discovered of miliary tuberculosis in a state of cure ; that is to 
say, the tubercles were found inclosed in a black pigment. 

Dr. Lawson says of laryngeal phthisis : " As described by Trousseau 
and Belloc, laryngeal phthisis is a chronic inflammation, upon which 
tubercular deposits may or may not be engrafted." This is scarcely a 
correct statement. The authors named used the word phthisis in the sense 
which was attached to it by all writers before Laennec, viz., a disease which 
proves fatal by wasting. Confining their attention to such diseases of the 
larynx, they described a simple, a sympathetic, a cancerous, and a tubercu- 
lous, laryngeal phthisis, and they defined the last named one to be " that 
form which begins to show itself after the existence of pulmonary tubercles 
can be detected." 1 Dr. Lawson, therefore, inverts the order of succession of 
the laryngeal and pulmonary affections as it is given by Trousseau and 
Belloc. 

Dr. Lawson suggests a reason why in certain cases tuberculosis fixes 
itself in the larynx. He supposes that in the " diathetic state," casual irri- 
tations of the larynx determine the development of tubercles in this organ 
rather than in the lungs ; and he adduces the inordinate use of the voice, the 
inhalation of irritating substances, as causes of this nature. Unfortunately, 
however, for the stability of this conclusion, it is not a fact that any of these 
persons are peculiarly liable to laryngeal phthisis. Grinders and others who 
inhale irritating particles suffer from bronchitis and not from laryngitis. 

Dr. Lawson admits that when phthisis begins in the lungs the larynx 
becomes involved in tubercular disease, and indeed declares that all the 
cases of laryngeal phthisis which have fallen under his observation were 
associated with pulmonary tubercles. Yet he affirms that in laryngeal 
phthisis, properly so called, the disease must begin in the larynx and trachea, 
and predominate in them throughout its entire course. Indeed, he goes 
farther, and lays down as a diagnostic point that in laryngeal phthisis the 
morbid action begins in the throat : Or, still more specifically he asserts that 
"there is an idiopathic laryngeal phthisis and a secondary laryngeal affec- 
tion, the latter a mere sequence or complication of ordinary chronic phthisis. 
The laryngeal affection which is generally idiopathic begins in the throaV 
(p. 404.) We have shown elsewhere that follicular inflammation of the 
throat has no relation, either causative or coincident, to tubercular disease 
of the respiratory organs, and now need only remind the reader of this fact, 



1 La Phthisie laryngee, p. 90. 



168 



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which is so persistently ignored by the author of the work before us. We 
have further to notice the still more erroneous assertion that there is such 
a disease as idiopathic laryngeal phthisis independent of cancer and syphilis, 
and of tubercles in the lungs. This proposition forms the basis of a system 
of quackery which certain unscrupulous practitioners of medicine, at home 
and abroad, have inaugurated and built up for the purpose of deluding the 
unhappy victims of consumption who are ever ready to grasp with the energy 
of despair whatever hope maybe thrown out to them, however delusive may 
be its promises' and how unsubstantial soever the succour it can afford. "We 
regret to see it incorporated in a work which contains so much of scientific 
truth, and adopted by an author whose sagacity, experience, and skill im- 
part to his conclusions a peculiar weight. At the risk of appearing prolix, 
we feel the question to be of such importance as to warrant our quoting, for 
the information of those who have not had leisure to study the subject for 
themselves, the conclusions of some of those pathologists whose original 
investigations have most largely contributed to settle the laws of tubercular 
disease. 

Louis originally established the pathological law, that in phthisis ulcers 
are more numerous in the larynx than on the epiglottis, and in the trachea 
more so than in the larynx. 1 He found also that in 18 cases in which the 
epiglottis was ulcerated without the participation of the larynx or trachea 
in the lesion, the pharynx and the tonsils were perfectly healthy, (p. 296.) 
Finally, as showing the close connection of ulcers of the larynx and trachea 
with tubercle, he found no instance of their -occurrence in five hundred autop- 
sies of persons who had died of chronic diseases other than phthisis, (p. 55.) 

Trousseau and Belloc testify as follows : " We recognize the existence of 
tubercular laryngeal phthisis whenever there is at the same time confirmed 
consumption of the lungs. So that in the former disease we shall find the 
signs of tubercular pulmonary consumption superadded to those of simple 
laryngeal phthisis." 2 Again, "We conclude that in tuberculous laryngeal 
phthisis, death by consumption is due not so much to the disease of the 
larynx as to the other organic lesions which accompany rather than follow 
it. In fine, tuberculous laryngeal phthisis is only the local expression or 
manifestation of a general disease." (Ib., p. 239.) 

Dr. Stokes says : " Indeed, what is called phthisis laryngea seems to be, 
in almost all cases, phthisis pulmonalis." 3 And again, "I can avow, that 
after ten years of hospital and private practice, I never saw a case present- 
ing the symptoms of laryngeal cough, purulent or muco-purulent expecto- 
ration, semi-stridulous breathing, hoarseness or aphonia, hectic and emacia- 
tion, in which the patient did not die with cavities in his lung." 4 

The immense experience of Grisolle and his consummate skill in observa- 
tion led him to this conclusion : " In the numerous autopsies I have made in 
the course of twenty-seven years I have never seen a case of primitive ulcer- 
ation of the larynx, and I have met with no authentic example of the sort 
in any work." 5 

Hasse expresses himself thus: "Nor am I aware of any instance of the 
larynx and trachea running through a course of tubercular disease inde- 
pendently of pulmonary phthisis," and he adds, "in most cases the pulmo- 
nary affection pre-exists." 13 

> Op. cit., p. 52. 2 Phthisie laryngee, p. 225. 

3 Diseases of the Chest, p. 246. 4 lb., p. 254. 

5 Pathologie interne, 7eme ed., i. 330. 

6 Path. Anat., Syd. Soc. ed., p 355, 356. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 



169 



Among the cases observed by Dr. Cless, of Stuttgardt, "not a single 
one appears where the tuberculosis or ulceration of the larynx and trachea 
formed the primary and predominant affection ; it was always secondary, 
and attendant upon simultaneous disease of the lungs." 1 

Even Dr. Cotton is obliged to confess, when speaking of laryngeal 
phthisis, "Perhaps, in every case of its occurrence, the lungs are found to 
be likewise tubercular." 3 

In his treatise on Pathological Anatomy, Foerster says, "Tubercle of 
the larynx is commonly, indeed almost always, an epiphenomenon of pul- 
monary tuberculosis, and extremely rare as a primary affection." 3 

In a very thorough examination of the subject of laryngeal ulceration, 
Dr. Rheiner declares that "strictly speaking there is scarcely such a disease 
as tuberculosis of the larynx," 4 that is to say, independently of tubercles in 
the lungs. 

Copland states the doctrine thus : "In laryngeal phthisis the affection 
of the larynx is merely symptomatic of tubercular formations in the lungs." 5 

Lebert, whose authority on this subject is perhaps superior to that of any 
other man, because he is equally distinguished as a practitioner of medicine 
and as a pathological anatomist, assures us that he " never met with an 
example of an idiopathic ulcer of the larynx." He even disbelieves the 
existence of tubercle in the laryngeal follicles, saying : " I have never de- 
tected tubercular matter in laryngeal ulcers. The so-called crude tubercle 
of the mucous membrane is nothing more than a swollen follicle containing 
its proper secretion in a state of fatty metamorphosis." 6 

Finally, the general law of the subject is laid down thus by Rokitansky : 
"Tubercles of the intestine, the larynx and trachea, the serous membranes, 
the spleen, and liver, occupy a very subordinate position, because they occur 
more or less rarely, indeed almost never, as primitive formations." 7 

It cannot be doubted that the doctrine expressed in these quotations is 
that of all the leading pathological writers whose judgment would be de- 
serving of any weight in reference to the present subject. When, therefore, 
Dr. Lawson speaks of a laryngeal phthisis "which is strictly idiopathic, 
begins in the pharynx, and involves, as a general rule, the tonsils, mucous 
follicles, larynx, and trachea," (p. 404,) he is describing that which either 
has no existence in nature, or if it exists, has remained invisible to all the 
most eminent cultivators of pathology. 

The treatment of phthisis is discussed by Dr. Lawson in a number of 
separate sections, in which are successively considered the management of 
The Precursory Stage, that of Tubercular Deposits, of Softening, of Cavi- 
ties, the treatment of Incidental Symptoms, and of Complications. A 
chapter is specially devoted to Inflammatory and Acute Phthisis, and 
another to Special Questions, particularly Sea Yoyages, Change of Climate, 
Gestation, and Topical Medication. 

If this method renders necessary the repetition of many statements under 
the several heads, and therefore adds much to the author's labour, and some- 
thing to the trouble of the reader who desires to learn the value of the differ- 
ent remedies discussed, it has the important practical advantage of grouping 
together the considerations applicable to each successive stage of the dis- 
ease, and therefore of rendering the precise information which is desired 

1 Ranking's Abstract, Am. ed., 1845, Pt. ii. p. 57. 

2 On Consumption, p. 172. 3 Patholog. Anat.,ii. 217. 

4 Virchow's Arcliiv, v. 549. 6 On Consumption, &c, p. 85. 

e Handbucb d. prakt. Med., i. 973, 969. ' Op. oit., i. 306. 



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more readily accessible to the practitioner. Of this division of the work, 
as a whole, we think that a very favourable judgment will be pronounced. 
It displays, generally, a just appreciation of the relative value of remedial 
measures in pulmonary consumption, and describes with clearness and pro- 
priety the special indications and the most successful methods of meeting 
them which are presented in the various forms, grades, and periods of the 
disease. 

The subject of climate as a remedy in pulmonary consumption has been 
discussed in all of its relations by a great many writers, and certain general 
conclusions have been arrived at which may be true of the majority of a 
given number of cases, but which are utterly fallacious in their application 
to individual instances. The same is, however, true of all therapeutical 
rules and principles, and every case of disease requires a mode of treat- 
ment adapted to its peculiarities. Observance of this rule only can insure 
success, and it is in perceiving and being appropriately guided by it that 
certain practitioners display sagacity and obtain more favourable results than 
their less acute brethren. It may be very true, for example, that in a warm 
climate phthisis is less prevalent than in a cold one, but it by no means 
follows that all consumptive patients would be benefited by a change from 
the latter to the former. Humidity and heat will pretty certainly be more 
mischievous than a dry and cold atmosphere, at every stage of the disease, and 
none the less for the malaria which accompanies the former during the 
summer and autumn, and which has been imagined to act as an antidote to 
tuberculosis. A dry atmosphere and an equable and not extreme tempe- 
rature, are the two essential elements of a climate favourable to persons 
affected with this disease. Such an one in this country, Dr. Lawson says, 
is enjoyed by the eastern portion of Tennessee, the high pine woods of the 
Carolinas and Georgia, and the middle and northern portion of Texas. 
He is also of opinion that an analogous climate will be found in New 
Mexico, Santa Fe, California, and Oregon, and that these places are suit- 
able resorts during the winter season. In summer, on the other hand, the 
North Western States, and especially the region about St. Paul, is recom- 
mended as remarkably salubrious. The peculiarities of the climate in most 
of the American and foreign resorts for consumptive invalids are very fully 
and intelligibly described by Dr. Lawson, particularly in the chapter devoted 
to Special Questions in the treatment of Phthisis. Dr. Copland treats 
of this subject quite at length and in some respects more minutely. As 
Dr. Lawson very appropriately remarks, however, the mere change of 
atmosphere, diet, and general associations, acting on both body and mind, 
modifies the common condition of the system, interrupts the morbid action, 
and restores the healthful play of the vital powers. Yet, in making choice 
of a residence for a consumptive patient, we must not be influenced by 
atmospheric conditions alone. To exile a person accustomed to the rela- 
tively complete and mechanical civilization of our northern cities, where 
every thing breathes comfort, and every want, every caprice, even, can be 
gratified, for life in a public house, ill built, rudely furnished, foul from 
untidy house-keeping, surrounded within doors by a crowd of wan and 
ghostly invalids, forever comparing notes of their pulses and their pains, 
their loss or their gain of weight, their ingesta and excreta — this is to con- 
demn him to despair and premature decay, and fill with flints and thorns 
the pathway which to the last step of its decline should be bathed in sun- 
shine and perfumed with flowers. Whatever locality is selected, if any 
must be away from home, let it be where the body may be invigorated by 



1861.] Lawson, Copland, Alison, &c, on Phthisis. Ill 



active exercise, or by protection at least from hostile influences, and the 
mind at the same time refreshed by the presence of natural objects, or the 
study of works of art, and as much as possible diverted from that sad self- 
contemplation to which all invalids are prone. 

Among the medicinal agents for the treatment of phthisis, Dr. Lawson 
ranks iron very highly, and recommends it associated with quinia. The 
iron treatment, indeed, he regards as an essential part of the therapeutics 
of tuberculosis, and as adapted to every form and condition of the disease 
(pp. 420 and 436) ; but he fails to notice a special indication for its use 
which we regard as essential to securing its benefits. It was very distinctly 
laid down by Morton, who says : " If the hectical heat be moderate and al- 
most insensible, .... the patients must be put upon the use of chalybeate 
waters in the summer. By this means I have relieved a great many of this 
kind of consumptive persons for many years, restoring their appetite, their 
flesh, and strength, abating their hectic heat and cough, and giving them a 
greater freedom of breathing, and that not only during the time of their 
drinking the waters, but also all the next winter." 1 The condition here 
insisted upon we have repeatedly found to be essential to a successful use 
of the medicine, for, when it was disregarded, hemorrhage has almost inva- 
riably resulted. We quite agree with Dr. Copland in his opinion that the 
effects of chalybeates of all kinds require to be closely watched in every 
stage and state of the disease, and while giving them in cases of very chronic 
phthisis without fever and with a limited deposit of tubercle, we cannot 
forget how completely Louis failed to realize the promises contained in the 
ardent and highly-coloured eulogy which Dupasquier pronounced upon the 
iodide of iron. 

Dr. Lawson is also convinced of the usefulness of quinia in the forming 
as well as in the subsequent stages of phthisis, by improving the tone of 
the nervous and digestive systems, and of the capillary circulation, and by 
preventing the occurrence of chills in all stages of the disease. Dr. Cop- 
land appears to restrict its use to conditions in which it is desirable to have 
recourse at the same time to an acid and to an astringent, while Dr. Rich- 
ardson regards it as of great value where the hectic attacks are regular. 
We believe that it is then almost exclusively that the medicine is of decided 
although of temporary utility. When a tonic influence is required, we 
regard cinchona or its extract as much superior to quinia. But neither 
can possibly operate more advantageously than a host of other remedies 
which may indeed palliate particular symptoms of consumption, but have 
no power to alter the diathesis out of which it proceeds, or to check the 
progress of the disorganization to which it naturally tends. 

The proper regulation of the diet in consumption is of more consequence 
than the administration of medicines. The accepted doctrine of the pro- 
fession is that the food should be very nutritious, and, if the stomach is 
unable to assimilate it, that active exercise and alcoholic stimulants should 
be resorted to for strengthening the digestive powers. Horseback exer- 
cise, and beefsteak and porter for food, are prescribed as the representa- 
tives of this view of the subject. Dr. Lawson thinks that there is an 
error in the practice ; that our object is to check the perverted transforma- 
tion, which could hardly be accomplished, he says, by crowding into the 
system large proportions of nitrogenous elements of food, which actually 
render the oxidation of the tissues more active. Hence, besides articles 



1 Op. cit., p. 160. 



U2 Reviews. [July 

which contain fat, he would recommend potatoes, wheat bread, rice, &c. 
We find, however, that he specifies beef, mutton, venison, birds, chickens, 
fish, and oysters, as appropriate animal food, and we are sure that no one 
need complain of such a bill of fare. In practice he is, therefore, like most 
other men, superior to his theory. A similar fact may be noticed of Dr. 
Bennett, according to whose theory consumptive patients ought to be dys- 
peptic and unable to tolerate animal food. He also proscribes farinacea 
because they produce the acidity which is required for the production of 
tubercles in his theory of their origin. Nevertheless, he tells us that the 
diet should be " of a nutritious kind, consisting of a good proportion of 
animal food abounding in fat ;" but he takes care to add — what is indeed 
the essential condition of such a diet's utility — that exercise, the strongest 
stimulant to appetite, must be taken actively and habitually. It is worthy 
of notice that Morton strongly insists upon a highly nutritious diet, as 
game, shell-fish, animal broths and jellies, in the more chronic forms of the 
disease ; while in its febrile condition, he recommends milk— particularly 
asses' milk. Gueneau de Mussy says that the food should be substantial 
and strong, proportioned, however, to the power of the digestive function, 
and he gives the good advice to avoid all ragouts, spices, salt meats, pastry, 
confectionery, and everything which expends the power of the stomach 
without affording nutriment. 

In reference to the use of alcoholic stimulants in phthisis, Dr. Lawson 
has some very judicious remarks. He says that they improve digestion, 
promote nutrition, and protect the tissues from a too rapid oxygenation. 
He very wisely dissuades from their use in the laryngeal complications of 
the disease, and concludes, that while they are most useful for persons of a 
phlegmatic temperament, they are least so in the bilious/ Malt liquors, he 
remarks, will be best adapted to the sanguineous temperament (which, 
however, is rarely that of consumptive persons), ardent spirits to the 
lymphatic, and wines to the nervous. Dr. N. S. Davis 1 has endeavoured 
to prove that there is no evidence that alcoholic stimulants are capable of 
either preventing or retarding the development of tubercular phthisis. For 
this purpose he inquired into the previous habits as regards temperance of 
a certain number of consumptive patients in a hospital. Evidently, this is 
entirely irrelevant matter. If the population of a place could be divided 
into two or more parts, according as they abstained from or used alcoholic 
beverages in moderation or in excess, and the percentage in each one could 
be determined, a partial solution of the question might be attempted. But 
even then the influence of other causes favourable or unfavourable to the 
disease would have to be estimated ; and this is perhaps impossible. For 
example, it is certain that females are less addicted than males to the use 
of alcoholic drinks, so much less so that if no other causes interfered, and if 
alcohol is per se anti-phthisical, they should present a much greater mor- 
tality than males from phthisis ; whereas, we know that if the two sexes 
differ at all in this respect, the difference is in favour of the males. Again, 
the intemperate use of alcoholic beverages may, by its debilitating influence, 
tend to precipitate the development of tubercles iu those who are predisposed 
to them, while their moderate employment may invigorate all of the physical 
powers and ward off the imminent danger of the disease. The question is 
scarcely one which can be solved statistically; but we suspect that alcoholic 
drinks will continue to be prescribed, either theoretically, because they 



1 Trans. Am. Med. Assoc., xiii. 565. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 



173 



diminish the waste of the system just as fatty nutriment does, or practically, 
because they who employ them in moderation, along with their food, and 
in conjunction with active muscular exercise, feel all the better for their 
use. As for the suggestion that to prescribe them is to foster intemper- 
ance, it savours very much of the spirit which withheld men from deeds of 
mercy lest the ritual of their religion should be infringed. It is very certain 
that neither alcohol nor any other medicine or agent whatever can much 
diminish that vast crowd, one-seventh of the whole multitude of human 
beings who annually perish in many nations ; and if there be those who 
lift their eyes in pious horror that here and there a consumptive has sunk 
into the drunkard's grave, let them, if possible, be comforted by the reflection 
that by means of this potent elixir many a life has been prolonged to benefit 
society, and to brighten those golden chains of love which link families 
together, and friends to friends. 

The use of cod-liver oil is fully considered by Dr. Lawson. His results 
agree in the main with those of other observers who have published their 
experience since the first exaggerated statements upon the subject were 
made. He agrees with all others that it is a common occurrence for the 
pulmonary disorganization to proceed uninterruptedly even while the weight 
of the patient is increasing. He presents us with none of those surprising 
cures which appear to have taken place in the practice of a few physicians. 
He admits that the oil often disagrees with the stomach, especially in per- 
sons of a bilious constitution, and is of opinion that in the second stage 
of the disease, its free use tends to obstruct the pulmonary capillaries, and 
thereby to favour the local disease. In the third stage, or that of cavities, 
Dr. Walshe believes that it relatively produces more marked effects than in 
the previous stages ; but of this period Dr. Lawson speaks despondingly, 
and qualifies his hope of its benefits by the expression " if cavities are ever 
healed." It may be interesting to the reader to learn the opinion arrived 
at by so accomplished a physician as Lebert. He has expressed it in the 
following terms : — 

"It is undeniable that in an early stage of the disease, with appropriate hygi- 
enic treatment, and after many months' use of the oil, the course of a moderate 
proportion of cases is rendered milder and slower, and that more patients are 
improved, or even temporarily cured, than by a merely expectant treatment. In 
advanced phthisis the medicine is of less utility ; but it is occasionally useful by 
diminishing the colliquative sweats and delaying the emaciation : many patients 
it temporarily benefits, and some even permanently. It is a precious but by no 
means a specific remedy in phthisis, and has no direct influence upon the process 
of tuberculization." 1 

The topical medication of the fauces and air-passages finds an advocate 
in Dr. Lawson, who, if he does not go the whole length of some who have 
written upon the subject, yet lays himself open, in more than one place, to 
serious criticism : — 

" The removal of a portion of the tonsils," he remarks, " is particularly insisted 
upon by Dr. Green ; and, according to his extensive observations, great benefit 
is derived from the measure. When these glands are found secreting morbid 
material, and exhibiting diseased action throughout their substance, I am satis- 
fied that great benefit will be derived from the excision of the diseased portion.'' 
(p. 429.) 

Yery possibly when the supposed case exists, the treatment mentioned 



1 Handbuch, ii. 145. 



Reviews. 



[July 



may be appropriate. But we can say emphatically that no such case has 
ever fallen under our observation, and we are not acquainted with a single 
author, except such as have copied the statement which Dr. Lawson himself 
borrows, who has described this condition of the tonsils as an incident of 
phthisis. We cannot but regret, therefore, that Dr. Lawson should not 
have presented us more explicitly with his own experience in regard to this 
alleged complication. 

Dr. Lawson declares himself to be "fully persuaded that in the initial 
stage of laryngeal phthisis the judicious employment of leeches, counter- 
irritants, and the internal application of the nitrate of silver, may arrest 
the disease." (p. 514.) As we have already seen, he admits that the 
laryngeal ulcers of phthisis are due to the softening of tubercle (p. 403); 
yet we are called upon to believe that not only is this local application 
competent to procure the cicatrization of such ulcers, but to prevent new 
ones from forming, originating as they do, not from a local irritation, but 
from a constitutional cachexia ! He leaves out of sight altogether the still 
more important fact which we have already shown to be established by the 
concurrent testimony of all pathologists, that tuberculization of the larynx 
implies the same condition of the lungs. Far be it from us to depreciate 
the value of topical applications, liquid, pulverulent, and gaseous, in this 
affection, but we do most positively aver that no case of it was ever cured 
by them. Its more distressing symptoms may be mitigated, they may pos- 
sibly be for a time suspended — although of this we have never met with an 
instance — but that they have been cured no evidence has yet been furnished. 
They who affirm that this miracle has been performed surely do not reflect 
how heavily they tax our faith. If there are no signs of pulmonary tuber- 
culosis, upon what grounds are we asked to believe that the laryngeal affec- 
tion is tuberculous ? Can it be distinguished by its proper local symptoms 
from syphilitic ulceration of the organ, or from other forms of chronic, 
non-ulcerative laryngitis ? The distinctive sign, according to Dr. L., of 
coincident faucial inflammation has not been visible to other observers. We 
are, therefore, left without any satisfactory diagnostic character of laryn- 
geal phthisis, unless we recur to that of the simultaneous indications of 
tuberculous deposit in the lungs, and, if these exist, we shall surely not be 
pressed to believe that a cure of the laryngeal disease is possible. 

In regard to applying medicinal substances to the air-passages, Dr. Law- 
son refers to medicated fumes and watery vapours, and impalpable powders 
of various stimulant or astringent substances, as occasionally of use; but he 
thinks, in common with most other practitioners, that when the larynx is 
the principal seat of disease, nitrate of silver is incomparably the best appli- 
cation. It surprises us not a little, however, to observe that he both believes 
in the feasibility of introducing a probang into the air-passages, and advo- 
cates its use : — 

"It has now," he remarks, "been proven that the sponge-probang and elastic 
tubes can be introduced into the larynx without serious inconvenience to the 
patient. Having been in the habit for years of introducing the sponge into the 
larynx, and more recently the elastic tube, I am not permitted to doubt the 
practicability of these operations." (p. 543.) 

Other physicians there are who entertain quite as little doubt as our 
author upon this subject, and would have us believe that it is quite as easy 
an operation as the introduction of a catheter into the urethra, or even 
easier it may be. Dr. Scott Alison, at his first essay, "found some little 
difficulty, but after this, acquiring confidence and some tact in its perform- 



1861.] Lawson, Copland, Alison, &c, on Phthisis. 1T5 

ance, all difficulty soon vanished. 7 ' 1 Dr. Prosser James does not think that 
those who oppose the practice have given it a candid consideration, and 
feels it "somewhat unsatisfactory to be assured that no probang can pass 
beyond and between the vocal cords," and yet for this assertion to be 
followed by confessions that " a tube may be introduced for the purpose of 
artificial breathing.' 73 The only wonder is that Dr. James should ever have 
imagined so strange a proposition as that because a smooth and open tube 
may sometimes be tolerated by the larynx, therefore breathing can be per- 
formed through a body impermeable to air. As for Dr. Alison's remark, 
it was evidently made while he was yet in his novitiate of the art and 
mystery of laryngeal cauterization. But that a physician of so much in- 
telligence, information, and experience as Dr. Lawson should, in the face 
of demonstrations showing the all but physical impossibility of the opera- 
tion, hazard so definite an affirmation as the one we have quoted, without 
affording us even a glimpse of the grounds upon which his conviction rests, 
is a fact which we are wholly at a loss to explain. 3 Dr. Lawson must 
know very well that the greater number of those who affirm the feasibility 
or the facility of the operation are justly open to the suspicion of a want 
of candour ; several of them, indeed, being of that class who write thin 
octavos and puny duodecimos, full of startling assertions, as seemingly a 
more legitimate and certainly a more successful mode of advertising them- 
selves than a paragraph published in the columns of a newspaper, but one 
not a whit more fitted to inspire confidence in their integrity or their skill. 

As we have seen, Dr. Lawson assures us that for years he has been in 
the habit of introducing the sponge into the larynx, but offers us no 
proof of the fact except his own conviction, which is most respect- 
able presumptive evidence, certainly, but not a demonstration. Dr. Lente, 
of Cold Spring, N. Y., 4 appears also to have been astonished at the rash- 
ness of denying the possibility of the operation, for Dr. L. had a case 
which he thinks "completely settles" whether a sponge can be passed into 
the upper opening of the larynx, " and to a certain extent" also its pas- 
sage through the chordae vocales. On meeting with this statement, we 
eagerly read the writer's narrative, hoping to find in it a demonstration which 
elsewhere we had sought diligently but in vain. To our surprise it turned 
out that a patient had a small fistulous opening in the trachea, and when 
a solution of nitrate of silver was applied to the upper orifice of the larynx 
the edges of the opening were found to be stained. The author then adds: 
" This case establishes the fact that it is practicable to introduce the sponge 
into the larynx, and to introduce medicated solutions {I do not say the sponge) 

1 The Medication of the Larynx and Trachea, p. 3. 

2 Sore Throat, &c, p. 42. 

3 The originator of the alleged operation, Dr. Green, pitched his description and 
laudation of it on a key which Dr. Lawson does not attempt to reach, and even 
awakes that much enduring bird, the American eagle, to a shrill scream in his 
behalf. He claims that the sponge probang " has been in a thousand instances" 
thrust down " between and beyond the vocal chords, and has been carried not only 
through the trachea and its bifurcations, but at different times, and in the presence 
of more than five hundred different medical men, has been passed at will, into the 
right or left bronchial divisions ! I shall now give proof ... of our ability, as 
Americans, to accomplish still more than this for the treatment of thoracic diseases ; 
to perform operations of which conservative Englishmen and sceptical Frenchmen 
have never dreamed." (Amer. Med. Monthly, Jan. 1855, p. 11.) We had not 
supposed that Americans could thus impliedly be accused of carrying off the palm 
for credulity. 

4 N. Amer. Med.-Chir. Rev., ii. 78. 



176 



Reviews. 



[July 



into the trachea.-' It of course proves nothing more than that the caustic 
solution entered the trachea on the application of the sponge to the laryn- 
geal opening, a fact which we are not aware that any body has thought of 
calling in question. 

In truth, the weight of evidence against the assumption (for it is nothing 
more) that the sponge of a probang can be safely introduced into the 
larynx and trachea is wholly overwhelming. We need only remind our 
readers that in a report presented to the Xew York Academy of Medicine 
in 1855, by Drs. Parker, YYood, Metcalf, and Stone, of a committee ap- 
pointed to test the assertions of Dr. Green, it is stated that in no single one 
of all the trials made by them did the sponge satisfactorily enter the trachea. 
"In two instances the sponge was thought to have entered the larynx; 
but with repeated efforts it could not be passed between and beyond the 
vocal cords. The suffocation was so great each time as to compel a with- 
drawal of the instrument." 1 It is also pretty well known that an anato- 
mist and surgeon of no less eminence than Mr. Erichsen, upon purely 
anatomical grounds, as well as experiments, denies that the sponge probang 
has ever "in the living subject been passed beyond the true vocal cords.'** 
Mr. E. very pertinently asks how should the sponge be withdrawn if it once 
had passed this barrier ? The cords, like the edges of a buttonhole, would 
immediately close against the whalebone handle, and the sponge could 
only be extricated at the risk of lacerating the vocal ligaments and their 
investing membrane, or else the sponge itself might be left behind in the 
.air-passages. In 1855, Dr. Horace Green, in a paper published in a medi- 
cal journal, 3 and also presented to the Medical Society of the State of Xew 
York, 4 printed a letter from M. Trousseau, who says: "Xever, either before 
or since the publication of your labours, have I attempted to introduce into 
the larynx or the trachea a sponge saturated with a caustic solution 
and Dr. G. leaves it to be inferred that his correspondent acquiesces in the 
justice of his own claim to have performed that operation. M. Trousseau's 
courtesy to a correspondent may have deterred him from expressing an 
opinion of its feasibility, but that he did not believe it possible, is very cer- 
tain. Not only does he not mention affections of the larynx among those 
suitable for treatment by nitrate of silver, in the edition of his Therapeutics 
published in the same year, but in 1857 he is reported to have expressed 
himself as follows, in a clinical lecture : — 

" I have tried this operation very often after the directions of Dr. Green's 
treatise on the subject. I had tried it long before the appearance of that trea- 
tise, both on the living and on the dead subject. I have put all the good will 
possible into my experiments, and I have never been able to succeed. More 
than this. I have convinced myself that the operation, after this method, is 
impossible, and that it has never been accomplished by Dr. Green, or any one 
else." 5 

Dr. Ebert, of Berlin, is another of those who are unable to satisfy them- 
selves that the larynx can really be entered by the sponge probang. 6 and the 
number might be indefinitely multiplied. For ourselves, we disbelieve it 
altogether, and confess that we need stronger reasons than any which have 
yet been adduced by its advocates to convert us from our unbelief to faith 
in an assertion which is at variance with our own observation, unsustained 

1 N. York Journ. of Med., July, 1855, p. 148. 

2 Lancet, Nov. 1855, p. 489, and Dec, p. 51 S. 

3 New York Monthly, Jan. 1855, p. 1. 4 Transactions, 1S55, p. 237. 
5 Med. and Surg. Reporter, Aug. 1857, p. 408. 6 Edinb. Med. Journ., i. 54. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. lit 

by direct proof, and against which every anatomical and physiological rea- 
son militates. 

The operation of catheterism of the bronchial tubes for the purpose of 
injecting medicinal liquids, and especially a solution of nitrate of silver into 
the lungs, is spoken of favourably by Dr. Lawson, although less decidedly 
than laryngeal cauterization, because, as he remarks, he has had a less ex- 
tensive experience of its effects. Dr. Green, by whom this method of treat- 
ment has been proposed, states that he was indebted to Dr. Marshall Hall 
for the suggestion of introducing an elastic tube into the larynx in order 
to show the passage of air through it, and prove thereby the possibility of 
introducing a sponge into the same organ. The analogy of the two ex- 
periments is not a very evident one, and its suggestion is not very credit- 
able to the sagacity of Dr. Hall. It is singular, however, that Dr. Green, 
who borrowed from the treatise of MM. Trousseau and Belloc everything 
which he had before proposed in regard to the instruments used for the 
application of nitrate of silver to the larynx, even to the strength of the 
solution they employed, should have overlooked in that work a case of 
laryngeal disease reported by M. Fournet, who states that in its treatment 
he for the first time employed catheterism of the air-passages, which he also 
describes as an operation easily performed. 1 We pass by the absurdity of 
attempting to heal tuberculous cavities by means of any topical treatment 
whatever, to notice the question of the practicability, or rather the facility 
of introducing a flexible tube into the trachea, which M. Fournet represents 
as very great, and Dr. Green does not find difficult. On this point the 
Report made to the New York Academy of Medicine throws some light. 
It states that the operation had repeatedly been performed before, and even 
in ancient times; indeed, Dr. Green reminds us that in several cases of oedema 
of the glottis it had been used successfully by M. Sestier. It also states that 
with a tube having a large curve the attempt failed eight times out of nine- 
teen, and when a tube with a small curve was used the failures were nearly con- 
stant. The apparent power of the patient to inspire and expire air through 
the tube was found still to exist, though in a less degree, when the tube was 
in the oesophagus. The opinion of the operator as to whether the tube is in 
the oesophagus or the trachea was also shown to be fallacious, unless founded 
upon the general phenomena. Indeed, these symptoms were only too 
characteristic. When the tube was in the oesophagus the phenomena were 
chiefly negative; the voice, however, was distinct, and retching and vomiting 
were usual. In the trachea, however, the presence of the tube, while it 
caused little or no retching, extinguished the voice and occasioned in every 
case but one most frightful evidences of suffocation. The committee con- 
cluded, therefore, "that in the great majority of instances where injections 
are supposed to have been thrown into the lungs through a tube, they 
have passed directly into the stomach." In Germany, Prof. Griesinger, of 
Tubingen, made numerous trials of the new method, and was at first dis- 
posed to regard it as easy of execution ; but after longer experience he 
concluded that in nearly every case the tube had passed into the oesophagus, 
and had not entered the trachea at all. He was particularly struck with 
the inspiration and expiration of air which at first he supposed to come 
from the lungs; but he soon became convinced that if the stomach com- 
municated with the atmosphere by an open tube, inspiratory and expiratory 
acts must be performed by this organ, as well as by the lungs, under the 



1 Op. cit., p. 104. 
Eo. LXXXIIL— July 1861. 12 



US 



Reviews. 



[July 



influence of the diaphragm. 1 We may therefore consider this newer in- 
vention in pulmonary therapeutics as having little more intrinsic value than 
its immediate predecessor, as being in fact little more than a new device in 
medical legerdemain. 

A short chapter on the prognosis of phthisis concludes Dr. Lawson's 
work ; it is less precise than we could desire, and yet more positive than 
we believe to be warranted by fact. Thus we find it stated, as the general 
professional opinion, that phthisis "is measurably if not absolutely incur- 
able that the " precursory stage is very largely amenable to proper 
hygienic treatment;" and that "phthisis is, to a certain extent, a curable 
disease." On the other hand, we are assured, that "the present state of 
science justifies the assumption that tubercular exudation is susceptible of 
absorption ; and, furthermore, that tubercular consolidations may liquefy 
and return to the circulation, or be eliminated through the bronchial tubes, 
leaving in either case a condition of actual cure." The correctness of the 
first of the assertions quoted above may well be questioned. We do not 
know where, in the literature of the subject, he will find such an opinion 
expressd as that phthisis is absolutely incurable, and as to its being "measur- 
ably" so, or "to a certain extent," we presume that whatever degree of in- 
curability those words imply is admitted to exist. That the " precursory 
stage" is curable it is quite as impossible to deny as to prove affirmatively; 
that stage, as we have elsewhere shown, being a pathological figment. The 
absorption of tubercle, we must positively affirm, is not in the present state 
of the science a justifiable assumption. In physical science no mere assump- 
tion is justifiable. Nor can we for a moment admit that tubercle can liquefy 
and as such return to the circulation ; nor yet that the cretification of tubercle 
or its elimination through the bronchial tubes can be regarded as an "actual 
cure." At the very most these changes indicate a suspension of the local 
manifestation of the tuberculous diathesis. Indeed, Dr. Lawson admits this 
to be true in many cases, and states that the "mitigation of the disease may 
prove only temporary, and at a period more or less remote, the morbid con- 
dition will reappear and progress to a fatal issue." Nothing can be truer 
than this, but it is not in harmony with expressions previously quoted. 

If we examine the literature of phthisis, we shall soon be convinced that 
the idea of the absolute incurability of the disease was the offspring of an 
epoch almost fatal to the art of therapeutics, when inflammation formed 
the sole article of the pathological creed, when active measures for its cure 
consisted in the use of inordinate evacuations of blood and the secretions, 
and the mildest treatment was starvation. It was then that cases of 
phthisis ran their course most rapidly and least was said of even its tem- 
porary cure. But such a mode of cure was familiarly recognized even 
before the days of Auenbrugger and Laennec, and some writers claimed 
even more for medical art than its most sanguine advocates do at the pre- 
sent day. Sixty years ago Beddoes 2 wrote as follows: "Besides, shallow 
men, rendered insolent by success, loath to depart from prevailing opinions, 
have been satisfied to believe in the impossibility of dispersing tubercles, 
and, by consequence, of preventing or curing consumption in the great 
majority of instances." By way of proving the possibility of a specific 
being found for the disease, he cites the discovery of sorrel as a specific for 
certain scrofulous ulcers, and nitrous acid for some hepatic and venereal 
affections ! And after charging physicians with timidity or indifference in 

1 Deutsche Klinik, Apr. and July, 1858, p. 151 and p. 285. 

2 Essay on the Causes, &c. of Pulmonary Consumption, Lond. 1799. 



1861.] Lawson, Copland, Alison, &c, on Phthisis. H9 



regard to the subject, he refers to the twenty quarto pages of remedies for 
consumption published by Ploucquet ! He then proceeds to state that 
" an effectual remedy for consumption appears to have been nearly ascer- 
tained," and this (the reader will scarcely believe it) was digitalis ! "I 
daily see," he exclaims, "many patients in pulmonary consumption, advan- 
cing towards recovery with so firm a pace, that, I hope, consumption will 
henceforward as regularly be cured by foxglove, as ague by Peruvian bark." 
Yet, as we very well know, foxglove was destined to be added to the long 
list of remedies which he so unsparingly condemns. 

But, to go still further back, we find a higher authority than Beddoes 
vouching for the cure of consumption. Morton declares that crude tuber- 
cles do admit of a cure, either true or palliative, so that the patient 
"though he is sickly, and subject to fevers, even upon every little occasion, 
yet is able to do his ordinary business, and many times lives to grow old." 1 
But this remarkable and astute physician did not strive to overstrain the 
truth, for he subjoins : "Every consumption, though it be cured, is apt to 
return upon the least occasion." "Yea, even after the most perfect cure 
of a consumption, there is reason to suspect that there are some crude 
tubercles yet remaining, which at length may, by often meeting with an 
occasion, be inflamed, and ripen into apostemes, and so at last become 
open ulcers." Modern science has not permitted a more favourable prog- 
nosis than this to be formed. 

Tissot states, that the celebrated Swammerdam for many years expecto- 
rated calcareous concretions, and his lungs became a perfect quarry;* but 
his biography informs us, that he died in the last stage of marasmus at 
the age of fifty-three. Stokes refers to similar cases occurring in middle- 
aged persons. 

Laennec, himself, declares that "art may perhaps render the progress 
of the disease slower, but not cause it to retrograde," yet he adds: "quite a 
number of cases prove that after the evacuation of a cavity, a cure is pos- 
sible." (Op. cit, p. 98.) And Laennec concludes, that "the cure of 
phthisis by nature is possible, but not by art." (p. 280.) Such, also, was 
Andral's belief, founded upon the examination of bodies in the lungs of 
which he found cicatrices, empty cavities, and cretified tubercles. Louis 
arrives at a similar conclusion, but adds this caution which we shall do 
well to heed : "Let us not delude ourselves respecting the virtues of medi- 
cines, but remember that in some cases the progress of the disease is spon- 
taneously arrested and remains so permanently; while, on the other hand, 
after having remained stationary, for a long time perhaps, it may resume 
its course rapidly and without any apparent reason." (Op. cit., p. 651.) 
A very elaborate investigation of the curability of phthisis by Bogee, 3 led 
him to conclude that tubercles may calcify when few in number, and that 
cavities may possibly heal, leaving a permanent loss of substance, or a 
cicatrix with calcareous or fibro-cartilaginous or cellular matter. On 
these grounds the author indulges the hope that many tuberculous patients 
will hereafter be saved, while he frankly confesses that thus far the cures 
appear to be generally due to the efforts of nature alone. Rokitansky 
likewise describes the cure of tubercle as possible by shrivelling (Obso- 
lescenz), cretaceous transformation, or elimination after softening ; but, 
he adds, this is of little consequence to the consumptive patient unless the 
tendency to tuberculous deposit ceases at the same time. 4 Dr. Stokes 



1 Phthisiologia, p. 123. 

3 Archives Gen., 3eme ser. v. 191, 289, 460. 



2 (Euvres, iii. 59. 

4 Path. Anat., 3tte Aufl., i. 308. 



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separates phthisis into two varieties, the constitutional and accidental, "in 
both of which" he affirms that " we may effect a cure ;" but the reader of 
the present day will be surprised to learn that the treatment upon which 
this eminent physician depended when he wrote the words we have quoted, 
consisted among other things of leeches and mercury. 1 But these opinions 
were published twenty-five years ago, and were among the fatal fruits of the 
theory of the inflammatory origin of tubercle. Forget, a late eminent pro- 
fessor of Strasbourg, concludes his investigations relative to this matter as 
follows : " The only cases of tubercle susceptible of a permanent cure are 
those in which the deposits are small, few, scattered, and either remain 
undetected or of doubtful existence while the patient lives : other cases 
may undergo apparent cures, but they are only temporary, and sooner or 
later terminate fatally." 3 Dr. Pollock has observed that many persons get 
rid of all constitutional and local symptoms, and their health may be re- 
stored for years, but, he adds, "that such individuals eventually sink under 
the disease is true." 3 Dr. Edward Smith, in an essay on "The Curable Stage 
of Phthisis," (which is that hypothetical " pretubercular" stage already 
noticed in this article,) declares that while a cure, properly so called, may 
occur after the deposit of tubercle, it really does so in but an infinitely 
small number of cases, and in none are we able to predict so favour- 
able an issue. 4 It is well known that Dr. Bennett has enthusiastically 
maintained the curability of phthisis, and that nature herself accom- 
plishes the cure in "a vast number of cases." When he adds that she 
has done this in its incipient stage — i. e. by calcification of tubercle — he 
states what facts hardly warrant, except in the cases of persons past 
middle life in whom the disease, if such it can be called, is latent. He 
refers to six cases in the advanced stage of the disease in which the arrest- 
ment of the disease is ascribed by him to art, 5 and particularly to cod-liver 
oil ; yet he admits that any thing which will rouse the nutritive functions 
may produce the same effect. So Dr. Flint finds that in eight out of 
twenty -four cases of arrest of tuberculosis the cure " was evidently due to 
an intrinsic tendency to that result," 6 and that in the rest it depended upon 
a complete change of habits, from sedentary and indoor pursuits to active 
and even violent exercise in the open air. Upon the question before us no 
man living can speak with greater authority than Dr. Walsh e, and he gives 
no flattering prospect to the victims of consumption. He ignores entirely 
that limbo of a " pretubercular stage" in which the patient is not sound 
enough for health, nor diseased enough to be called tuberculous; he describes 
what Laennec and Louis so distinctly mention, that in phthisis the patient 
may go through successive attacks resulting from the maturing of succes- 
sive crops of tubercles ; and concludes that in a very small proportion, so 
small that it may be ignored, 7 an actual recovery takes place. Elsewhere 
(p. 38*1) he estimates the proportion of those in whom a complete restora- 
tion of function and the disappearance of active pulmonary disease takes 
place at four and a quarter per cent. In the excellent essay of Dr. C. 
Badclyffe Hall 8 the doctrine which we consider to be the true one upon 
this subject is stated in the following words : — 

" Of the absolute frequency with which such healing of a cavity takes place, 



1 Diseases of the Chest, 1837, pp. 442 and 447. 

2 Bull, de Therap., xxxiv. 16. 3 Lancet, Aug. 1856, p. 187. 
4 Edinb. Med. Journ., ii. 689. 5 Tuberculosis, p. 112. 

6 Am. Journ. of Med. Sci., Jan. 1858, p. 78. 

7 Am. ed., 1860, p. 377. 8 Brit, and For. Med. Chir. Rev., xvii. 46S. 



1861.] 



Sanitary Science. 



181 



we have no positive knowledge ; probably it is not extremely rare ; but of the 
infrequency with which it so takes place that the patient eventually recovers 
from his phthisis, we have sadly too established a conviction. The possibility of 
such a cure is quite certain ; but that we have a right to anticipate it in any 
case of undoubted tuberculous cavity in the lung, all experience forbids." 

We might multiply these citations from authors whose conclusions have 
the weight of laws in pathological science, and especially from among the 
great teachers of German medicine, but these will perhaps satisfy the 
reader that the sanguine expressions of faith in the power of medical art 
to cure phthisis are misplaced and premature, and that we should expose 
ourselves to less chagrin and our patients to less sorrow by admitting the 
unquestionable truth that in any given case of phthisis there is not one 
chance in a hundred of death being averted even for a few years. Not to 
recognize this probability, while we employ every means in our power to 
render each particular patient the fortunate exception to the law of mor- 
tality which weighs upon those affected with pulmonary tubercles, would be 
to close our eyes against the most evident conclusions of experience, and 
forswear our duty to those whom we are bound to serve. We should rather 
present to them the danger in its full proportion, and make its very mag- 
nitude a motive for them literally to work out their salvation from the fate 
which hangs over them. 

The prognosis of acute phthisis would seem, contrary to what has gene- 
rally been supposed, to be less unfavourable than that of the chronic form. 
Lebert claims to have seen not less than six examples of its cure. Four 
of these patients afterwards died of other diseases, and exhibited in their 
lungs the clearest evidences of cured miliary tuberculosis. 1 Several have 
also been published by Wunderlich. 3 The difficulty of diagnosis in this 
disease must throw a shade of doubt upon the nature of some of the re- 
ported cases, but the proof in those of Lebert is complete. A. S. 



Art. XI. — Sanitary Science. 

1. Proceedings and Debates of the Fourth National Quarantine and 
Sanitary Convention, held in the city of Boston, June 14, 15, and 
16, 1860. Reported for the City Council of Boston. Geo. C. Rand 
and Avery, City Printers. Boston, 1860. 

2. Public Health. The Right Use of Records founded on Local 
Facts; being two papers read before the National Association for the 
Promotion of Social Science, at Bradford, in October, 1859 ; with an 
account of subsequent proceedings. By Henry Wyldbore Rumsey, 
Author of "Health and Sickness of Town Populations," " Essays on 
State Medicine," &c. London, 1860. 

Whatever may have been the doubts of a few in anticipation of the 
meeting of the first Quarantine and Sanitary Convention of the United 
States, in 1857, there can be no question at the present date that it and 
those which have succeeded it have been productive of useful and important 
results. The difficulties attendant upon the inauguration of such an effort 



1 Handbuch d. prakt. Med., ii. 115. 



2 Archiv d. Heilkunde, i. 289. 



182 



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[July 



have been, to a great extent, met by the earnestness and practical ability of 
those by whom it has been carried forward. 

We have been, in this country, behind the nations of Europe, less in 
appreciation of the principles of public hygiene than in the administrative 
reforms which they should develop, and in the generality of interest of 
intelligent men in their advancement. 

The Quarantine Regulations of the United States have been, to this time, 
nearly identical with those imposed in the Colonial times ; while they have 
been undergoing modification in Europe for more than thirty years. 

All educated men in England, France, and Germany, now find in sanitary 
science favourite topics of inquiry and reflection ; while many of the im- 
portant legislative provisions of the states of central Europe, for the 
protection and preservation of the public health, are rather of Italian than 
Teutonic origin. At Rome, under the emperors Yalentinian and Yalens, 
"the poorest of the people shared with the household of Caesar the services 
of an honourable Iatrarchy;" and traces of the perpetuation of the Roman 
Medical Code are yet extant in Belgium. Farther back, we may remember 
that Hippocrates and Democedes held a medico-sanitary relation to the 
public, at Athens, ^Egina, and Samos. In Plato's ideal republic, the phy- 
sician had an essential place. 

In modern times, the earliest systematic treatise upon the subject of 
" Medicinische Polizei" or Medical Polity, appears to have been that of 
Johann Peter Frank, in 1T79. 1 Since that time Germany has furnished a 
number of able writers upon its different themes. In England, after the 
"twelve proposals" of John Bellers (1714), sanitary literature maintained 
a fragmentary state until a quite recent period ; while the action of govern- 
ment upon questions of public health has been designated by an English 
writer as "little dabs of doctoring done by different departments." 

As we have said, however, this is no longer the case anywhere in Western 
Europe, or in this country. While many questions both of principle and 
administration remain undecided, and while it may be true that "only the 
threshold of sanitary science has yet been reached," yet a great beginning 
of reform consists in the fact that preventive medicine is now appreciated 
as a necessary branch of social and political economy ; and that it has 
attained already important triumphs, both in lessening the intensity and 
prevalence of destructive diseases, and in mitigating or removing the bur- 
dens and inconveniences, personal and commercial, which ignorance and 
terror had long imposed. 

The share the American Quarantine and Sanitary Convention has taken 
in promoting these improvements, by giving the authority and influence of 
its sanction to principles before advocated by individuals alone, may be 
readily gathered from the present volume of its debates and proceedings. 
Believing, however, that its conclusions and enactments of previous years 
must be familiar to most of the readers of this Journal, it is necessary 
only to allude at this time to the confirmation which they have again re- 
ceived, and to the efforts made to extend and apply them. 

Upon the subject which was most prominent in the labours of previous 
conventions, the following resolution was passed by that of 1860, on mo- 
tion of Dr. Jewell : — 

1 John Evvich, the Medicus Ordinarius of Bremen, published in 1582 a singular 
book entitled De officio Jidelis et prudentis Magistrates in tempore Pestilentiae. 
Rumsey, Essays on State Medicine, p. 300. 



1861.] 



Sanitary Science. 



183 



" Whereas, at the last meeting of the Convention, after a learned and dispas- 
sionate discussion, the long agitated question of the non-transmission of yellow 
fever from one person to another was definitely settled ; in order to strengthen 
that decision, therefore 

" Resolved, that the action of the last Convention on the question of the non- 
contagiousness of yellow fever be, and is hereby reaffirmed." 

During the debates of the same session, and in the less formal speeches 
made by delegates on incidental occasions, confidence in the soundness of 
the views previously agreed upon was most freely and even enthusiastically 
expressed. Yet that these views are not extreme, is obvious from the cha- 
racter of the report of the Committee on External Hygiene, adopted 
almost without dissent by the Convention. 

This report is probably the most important part of the Transactions of 
the year. It was prepared by Drs. A. N. Bell, E. Harris, W. Jewell, R. 
D. Arnold, and H. G. Clark; including also a report on the " Utility of 
Wet Docks in connection with Quarantine," by Drs. J. W. Sterling, A. H. 
Stevens, and J. McNulty. 

Opening with a few prefatory remarks, a sketch is given, in the report, 
of the progress of the quarantine discussion and its relation to sanitary 
reform, since the time of Chervin ; awarding due credit to the French re- 
formers, Dupeytron, Aubert-Roche, and Melier, as well as to Chadwick, 
Guy, Southwood Smith, Duncan, Milroy, and others in Great Britain. 

The Committee then makes a statement of the special wants and faults of 
existing arrangements for "external sanitary defence;" under the two 
heads, I. The defects that relate to the sick and to sanitary protection ; II. 
The deficiencies that relate to commercial transactions and public conveni- 
ence. Under the first head are included hospital accommodations and 
facilities for the reception of patients, as well as the construction and 
management of docks and warehouses for quarantine purposes. Under 
the second head are mentioned the needless and expensive detention and 
delay of vessels and cargoes, the damage to such cargoes and vessels at 
quarantine, and the inconvenience and expense of lighterage. 

Several of these topics are emphatically dealt with in the report upon 
the Utility of Wet Docks in connection with Quarantine. 

Experience in the New York Marine Hospital has afforded reasonable 
ground for dissatisfaction with the facilities there and in similar establish- 
ments, afforded for the care of the sick. In sixty years ?2,595 patients 
have been admitted into that hospital, of whom 10,493, a seventh part, 
have died. 

" In order fully to appreciate the wants of a quarantine establishment, it is 
necessary to have been a spectator of some of its woes. In reading the history 
of quarantines as they have existed in various parts of the world, as well as 
legislative and other reports and communications relating thereunto, the para- 
mount and almost exclusive subjects of inquiry have been, How shall we protect 
our citizens against the invasion of pestilential disease ? How can we lighten 
the burdens which quarantine imposes upon commerce ? The speeding of the 
weary voyager and the care of the sick being regarded as of minor importance, 
too often is the poor squalid immigrant, as he is frequently called, shunned, 
loathed, and, if sick, even viewed as a culprit. We are not apt to appreciate 
their miseries, destitute, homeless as they are ; fleeing from famine and oppres- 
sion abroad; long pent-up in the hold of an ill-ventilated vessel; their sickness 
their misfortune, not their fault." 

The description of the Lazaretto San Leopoldo at Leghorn suggested 
to the writer of the report the advantage of wet docks in alleviating the 



184 



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[July 



sufferings of the sick on being landed at quarantine. At the same time, 
such docks would afford protection to the vessels themselves against the 
violence of storms, would secure their merchandise from plunder and loss, 
and would expedite the introduction of goods into the market. Having first 
landed passengers and cargoes, vessels needing purification may be cleansed 
and ventilated at the dock ; although very foul vessels will require the 
further use of dry docks for thorough expurgation. 

Commercial history has shown that, as at Liverpool and London, the 
construction of wet docks has done much to attract and facilitate commerce. 
The West India docks on the Thames comprise an area of two hundred 
and ninety-five acres. 

Very much less extensive accommodation, however, would be needed at 
any port for the purposes of quarantine. It is estimated by the Committee 
that a dock capable of affording room for thirty or forty vessels at a time 
would suffice as a maximum. 

The next section of the report of the Committee on External Hygiene 
is upon " Specific Measures of Quarantine, severally applicable to Yellow 
Fever, Cholera, Typhus, and Smallpox, with the variations which different 
localities require." 

Quarantine Hospitals are first considered. As to the distribution of the 
sick, the following remarks indicate the views of the Committee : — 

" While facts do not warrant the conclusion that any disease is necessarily 
and inevitably infectious or contagious under all circumstances, it is so true of 
smallpox and of typhus that they do certainly spread by personal contact, 
limited infection of apartments, and also by personal fomites, that it is manifestly 
the duty of the sanitary authority to insure the entire seclusion of each of those 
maladies. As regards both yellow fever and cholera, it will be generally admit- 
ted that it is due to public quietude, even if it is not known to be absolutely 
necessary for public safety, that persons arriving at quarantine with either of 
those maladies should be provided for in secluded hospitals. But it is safe to 
recommend that the local sanitary authority of any city or port should decide 
whether special hospitals be established exclusively for the sick arriving at 
quarantine, or whether the special hospitals established for the seclusion of the 
same diseases occurring in such city or port, be also used for the same class of 
patients arriving from abroad." 

This is going as far in the direction of reform as can be expected at the 
present time. As it was observed by a speaker in one of the debates of 
the Convention, " civil authorities will never move in advance of public 
sentiment, and public sentiment will never progress until it is enlightened." 
And thus, while a few scientific minds in this country, and many abroad, 
still advocate, with an earnestness of conviction that no preponderance of 
evidence can shake, the contagiousness of both cholera and yellow fever, it 
is perhaps, so far as public arrangements are concerned, " wiser to ac- 
quiesce, at least provisionally, in opinions" or practices " which have pre- 
scription in their favour ; and of which the refutation, if they be refutable, 
is not yet certain and complete." 1 Yet, we are confident that more than 
this will hereafter be done ; and that some future sanitary convention, at 
a time not very far distant, will insist that no more fear should be felt, by 
a community, of the persons of patients sick with yellow fever, or cholera, 
than is now felt of those suffering with pneumonia or influenza. 

As to location, it is urged that quarantine hospitals should be so con- 
venient of access from the quarantine anchorage, and warehouses, and 

1 Lord Stanley's Address on Public Health. Birmingham, 1857. 



1861.] 



Sanitary Science. 



185 



docks, as to afford the best possible facilities for the immediate medical 
care of the sick arriving, and of labourers or others becoming ill at the 
station. 

In regard to arrangements, such hospitals require, especially, 1. Ample 
air-space and effectual ventilation. 2. Proper supply and control of 
sunlight in the wards. 3. Such construction and material for the wards 
as not to favour the retention and perpetuation of febrile poisons and pesti- 
lent emanations. 4. Means for immediate and safe disinfection of all 
clothing, bedding, &c. 

The Committee recommends that the quarantine docks, warehouses, and 
anchorage, should be located at least two miles from any populous neigh- 
bourhood, however rural, and, when practicable, at a much greater distance 
from cities or large towns. The executive management of such establish- 
ments should be under direction of competent scientific officers. 

It is very properly observed that a ship arriving with typhus fever or 
smallpox at midwinter, is as legitimately a subject for quarantine restric- 
tions as one with yellow fever on board in midsummer. 

So important are the declarations of the Code of Marine Hygiene presented 
in this report, as to make it appropriate to quote some of them in full. 

" Every organized government has the right of protecting itself against the 
introduction of infectious diseases, and of putting any country, place, or thing 
in quarantine which would introduce infectious diseases ; provided, however, that 
no sanitary measure shall go so far as to exclude or drive from port a vessel, 
whatever may be her condition. 

" 2. The only diseases at present known against the introduction of which 
general quarantine regulations should be enforced, are, plague, yellow fever, 
cholera, smallpox, and typhus fever. As regards plague, the European Con- 
gress at Paris had the right to settle the question for the nations there repre- 
sented ; and, inasmuch as they and the other nations of the Eastern Continent 
have reason to subject the plague to quarantine restrictions, the States of 
America yield implicit obedience to that convention. 

" 3. All quarantine regulations, of any place whatever, should bear with equal 
force against the toleration or propagation of disease as against its introduction ; 
and authority to prevent the introduction of disease in any place, should be 
equally applicable against its exportation. 

" 4. All quarantinable diseases are chiefly introduced and propagated by the 
materiel of commerce ; and it is therefore against it that quarantine restrictions 
should be instituted, and not against the personnel; excepting, however, persons 
with no evidence of vaccination, and known to have been exposed to smallpox ; 
such persons shall be vaccinated as soon as possible, and detained until the 
vaccination shall have taken effect ; otherwise, they may be detained fourteen 
days from the time of the known exposure. 

" 5. The application of quarantine regulations shall be regulated by the offi- 
cial declaration of the constituted sanitary authority at the port of departure 
where the malady exists. The cessation of these measures shall be determined 
by a like declaration that the malady has ceased, after, however, the expiration 
of a fixed delay of thirty days for the plague, fifteen days for yellow fever, and 
ten days for cholera. 

" 6. It is obligatory on all vessels to have a Bill of Health ; this shall consist 
of two kinds only, a clean bill and a gross bill, the first for the attested absence 
of disease, and the second for the attested presence of disease. The bill shall 
state the hygienic state of the vessel ; and a vessel in a bad condition, even with 
a clean bill of health, shall be regarded as a vessel having a gross bill, and shall 
be submitted to the same regime." 

Provisions in detail are also elaborately set forth : as, I. Measures re- 
lating to Departure. II. Sanitary Measures during the Voyage. III. 
Sanitary Measures on Arrival. 



186 



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[July 



Under the last head we find the repetition of the principle that all well 
persons shall be allowed free pratique, excepting in cases of smallpox, 
as above stated. Ordinary cargoes of dry and imperishable goods are also 
admitted to free pratique after examination, with some temporary excep- 
tions. 

Merchandise to be submitted to obligatory quarantine and purification, 
comprises clothing, bedding, personal baggage and dunnage, rags, paper, 
paper-rags, hides, skins, feathers, hair, and all other remains of animals, 
woollens, and silks. 

Cotton, linen, hemp, and cattle are to be subject to optional quarantine. 
All other merchandise is to be exempt from quarantine. A foul ship, it is 
well said, is much more to be dreaded, as a vehicle of introducing disease, 
than anything she has on board. Such ships must be broken out and 
duly cleansed and ventilated before they can be properly allowed to enter a 
port or lie alongside of a wharf or other ships. 

The Committee furnishing this report was, on its adoption, directed to 
negotiate with the national government or department of State, to secure 
the national and international adoption of a code based upon the principles 
advanced in it. A committee of delegates from the several States repre- 
sented in the convention was also authorized to confer with the State go- 
vernments in regard to its adoption. 

Dr. D. B. Reid, of Wisconsin, a member of the same Committee, contri- 
buted an interesting " Summary," on the importance of an International 
System of Quarantine, which is appended to the report. 

The remaining reports published in this volume are upon " Registration," 
"Heat as a Disinfectant," " Civic Cleanliness, &c," and "Legal Control 
of Poisons and Dangerous Drugs." A few words only of remark being 
allowed us upon each of these, the first named will be taken up in connec- 
tion with the papers upon a similar subject, by H. W. Rumsey, named at 
the head of this article. 

Dr. Elisha Harris' paper upon the "Utility and Application of Heat as 
a Disinfectant" is a very interesting and instructive one. After a brief 
historical allusion to the ancient and modern use of fire 1 for the destruction 
of infection, and an account of the great difficulty and costliness which must 
make its employment unavailable on a large scale, he considers, at some 
length, the evidences of the disinfecting power of high temperatures short 
of a degree which would be destructive of ordinary textile fabrics and other 
materials likely to act as fomites. 

M. Violette has shown that dry vegetable tissues enter upon the first 
stage of carbonization at 222° Fahr. Ovens bake at from 320° to 400°; 
sulphur ignites at 560° ; cane-sugar melts at 320° ; and liquid albumen 
coagulates at about 145°. All vegetable life is extinguished at a tempera- 
ture far below that of boiling water ; and animal life is generally destroyed 
by a comparatively brief application of heat that coagulates albumen. All 
kinds of fermentative catalysis cease at a temperature still lower. All pro- 
cesses in nature, in short, which bear any analogy to the incubation, pro- 
pagation, and action of pestilent infections, are arrested or very essentially 
modified by high heat. 

Observation and experiment have confirmed the expectation thus de- 
rived, so far as they have gone. It is a commonly known fact, that the 
boiling or steaming of infected clothing effectually purifies it, while mere 
washing is entirely insufficient. 

1 See La Roche on Yellow Fever, vol. ii. chap. xxii. 



1861.] 



Sanitary Science. 



187 



In Berlin, in 1851, Dr. Yon Busch succeeded in disinfecting the wards 
of the lying-in hospital, by a dry heat of 150° Fahr., maintained for two 
days ; although puerperal fever had before obstinately clung to the house, 
in spite of all other measures of thorough cleansing. The same class of 
patients was immediately readmitted, without any occurrence of the disease. 
A year later, the pestilence returned, and was again annihilated in the 
same way, by the agency of common stoves. 

It is certainly rational to extend the expectation of similar results to the 
cases of hospital gangrene, erysipelas, and typhus, which so often cling to 
public and even private buildings, and, in the instance of the last disease, 
to ships. As to yellow fever, facts of positive value are given, as having 
occurred in the experience of Dr. Harris in the New York Quarantine Hos- 
pitals, and in that of Dr. A. N. Bell in the IT. S. Navy, in southern waters. 
Reference is also made to the instance of the British transport ship Begalia, 
narrated by Dr. William Ferguson. 1 For the details of these cases, we 
must refer the reader to the report itself. 

Some very interesting experiments were made upon this subject by Dr. 
W. Henry, F. R. S., of Manchester. His purpose was to determine, 1st. 
What elevation of temperature cotton and other substances likely to har- 
bour contagion might sustain without injury. 2d. That, in at least one 
unequivocal instance, contagious or infectious matter should be proved to 
be destructible at that temperature. As quoted by Dr. Harris, he ascer- 
tained that raw and manufactured cotton, silk and wool, fur and feathers, 
could be exposed for three hours to a dry heat of from 180° to 220° with- 
out injury. 

Yaccine virus was also found to lose its specific property after exposure 
to a heat of 140° or upwards. Further experiments with the clothing, &c. 
of patients having typhus and scarlatina, strengthened, although, of course, 
less definitely, the evidence in favour of the proposition that a temperature 
of 200° will destroy infection or contagion, without injury to the fabrics 
most likely to be its vehicle. 

Dr. Harris announces his full belief in this potency of heat, whether dry 
or applied by steam. He urges, however, that more extended experiments 
should be made upon various points connected with its use. For vessels, 
especially, steam will be found much the most convenient medium. No costly 
apparatus will be required ; steam-tugs upon the water, and portable steam- 
generators upon land can be made to serve the purpose at moderate ex- 
pense. 

As illustrating the absence of injurious action by high steam heat upon 
valuable fabrics, it is stated that, at the establishment of J. G. Scott, Esq., 
at Shemlan, near Mt. Lebanon, in Syria, vast quantities of silk cocoons 
are exposed to jets of steam, to destroy the vitality of the chrysalis, and thus 
preserve them in a state fit for reeling. This is effected in a few minutes, 
without any damage to the silk. 2 

We cannot avoid entertaining a sanguine hope that the investigations of 
Dr. Harris upon this subject may be pursued with such further success, 
upon a large scale, as to establish the importance of high heat, as being, 
with the exception of intense cold, the only reliable disinfectant, in the case 
not only of yellow fever, but of all analogous diseases. 

1 Royal Med.-Chirurg. Transactions, vol. viii. 

2 Prof. Bollman, of Russia, has found the potato-disease to be arrested, by drying 
the potatoes used for seed under a moderate heat; their germinating powers not 
being thus at all interfered with. 



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The report of Lieut. Egbert L. Viele, on " Civic Cleanliness, and the 
Economical Disposition of the Refuse of Cities," is deserving of a more 
extended analysis than our space will permit. It considers, succinctly, the 
four subjects of drainage, paving, supply of water, and sewerage, with 
practical suggestions upon each. 

In regard to drainage, local conditions must necessarily govern the ar- 
rangements required for each place. The cities of this country, having 
been built with reference chiefly to the convenience of trade, and having 
many of them grown with enormous rapidity, are much behind those of 
Europe in facilities for drainage. 

Paving is held by the author of the report to be of equal importance to 
the public health. The best pavement is asserted to consist of "small cu- 
bical blocks of primitive rock laid upon a bed of concrete." The old 
Roman pavements, which have survived everything around and above them, 
were constructed upon this principle. Cobble-stone paving is a mere tem- 
porary expedient. 

Rome affords also a salutary lesson (as was shown by Dr. John Bell in 
his report of 1859) as to the value of an ample water-supply, as well as of 
sewerage. " To her sanitary regulations she owed her imperial splendour ; 
to their neglect she owed her ruin." 

The report of Lieut. Viele also alludes to the causes of insalubrity con- 
nected with docks, wharves, piers, and bulkheads, as ordinarily constructed. 
A diagram is given, showing a plan for a wharf built on stone piers, the 
superstructure being of wood. 

Upon the topic of the " Economical Disposition of the Refuse Matter of 
Cities," Liebig's letter to Alderman Mechi, of London, is introduced, as 
affording a correct exposition of important principles. We have room only 
for a few sentences : — 

" A well, however deep it may be, which receives no supply of water, must, in 
the end, become empty, if its water is constantly pumped out. Our fields are 
like such a well. For centuries those elements which are indispensable to the 
reproduction of the crops have been taken from the soil in those crops, and that, 
too, without being restored. The loss of these elements is brought about by 'the 
sewerage system of towns.' " 

" History teaches that not one of all those countries which have produced corn 
for other lands have remained corn-markets, and England has contributed her 
full share towards rendering unproductive the best lands of the United States, 
which have supplied her with corn, precisely as old Rome robbed Sardinia, Sicily, 
and the rich lands of the African coast, of their fertility." 

"If it be perceived that no country can perpetually supply another with corn, 
then it must be still easier to understand that an importation of manures from 
another country must cease still earlier." " The prices of bones have already 

become so high in Germany as to forbid their exportation In relation to 

guano, I have been assured that in twenty to twenty-five years, if the use of 
guano should increase in even the same proportion as hitherto, there will not 
remain in South America enough to freight a ship." 

" It has been maintained that the recovery of the manure-elements out of the 
sewers of large cities is impracticable. I am not ignorant of the difficulties 
which stand in its way. They are indeed very great ; but if the engineers would 
come to an understanding with the men of science in relation to the two purposes 
— the removal of the contents of the sewers, and the recovery of their valuable 
elements for agriculture — I do not doubt that a good result would follow." 

The remainder of Lieut. Viele's report is occupied by the brief discussion 
of the best modes of disposal of city-refuse, under the several heads of street- 
cleanings, garbage, sewage, night-soil, and offal. It is apparent that no 



1861.] 



Sanitary Science. 



189 



perfectly economical scheme has yet been devised ; and although we are 
hardly ready to indorse the criticism of a member of the Convention, in the 
debate upon the adoption of the report, as to its having touched the matter 
"too lightly," yet we may hope that this is a subject to which the most 
practical minds will yet be devoted, until we obtain hereafter a remedy both 
for the sanitary evil and the economical extravagance. 

In Paris, the contractors who carry off the sweepings of the streets 
alone, realize upon the sale in the form of manure a total sum of $700,000 
per annum. The elevated site of Edinburgh allows its sewage to be distri- 
buted over a considerable tract of meadows, producing unexampled crops 
of grass, and commanding a high rent. In Birmingham, a new system of 
drainage and sewerage was commenced in 1840, by which, through the 
agency of a reservoir, three miles from the centre of the town, and capa- 
ble of holding six million gallons, the sewage may be made available. 
This reservoir will command the Tame and Trent Yalleys, one hundred 
miles in length, with a fall of upwards of four hundred feet. 

The Chinese and Japanese seem to have been in advance of western 
civilization in the use of night-soil as manure or poudrette. It is employed 
largely, however, already, in Belgium and France. 

Dr. C. B. Guthrie's report "On the Legal Control of Poisons," is the 
last in the volume now before us. Its purpose is to urge such legislation 
as will lessen the danger connected with the sale of dangerous drugs by 
imperfectly educated or irresponsible persons ; and also to make such restric- 
tions uniform in the several States. 

There appears to have been, in the debate in the Convention upon this 
report, considerable difference of opinion ; not as to the desirableness of 
these objects, but as to the means of promoting them. Several members 
objected to the specification of a list of poisons ; which was, accordingly, 
left out. We may observe, however, that Dr. Guthrie's argument in its 
favour seems to be supported by the fact that, as stated by Dr. A. B. Tay- 
lor before a committee of the House of Lords, of 540 deaths yearly, on an 
average, by poison, in England, three-fourths have been due to two sub- 
stances, arsenic and opium — while a list of thirteen articles includes nearly 
every case that is recorded. 

It was a question with some members of the Convention, apart from all 
doubt as to the practicability of more than merely palliative legislative 
reform, in this matter — whether it was an appropriate subject for the con- 
sideration and action of a sanitary body ? The same question was more 
positively urged in regard to the epidemic "pleuro-pneumonia" of cattle, 
upon which some remarks were made ; and it might have been extended, 
for analogous reasons, against the appointment of a committee upon the 
working hours of the labouring class. 

We cannot hesitate to agree with those who answered this question, in 
all of these cases, in the affirmative. All such subjects of investigation, 
action, and legislation, are relevant to public hygiene and preventive medi- 
cine; all are therefore appropriate to a sanitary convention. 

The disposition of the members to extend the field of labour beyond the 
anticipation of those who were the pioneers of the work, was shown by 
the appointment of a Committee on State Medicine. It is true that the 
duties of this Committee were not so enunciated as to justify the title given 
to it ; it being really a standing Business committee. But, such action 
indicated a consciousness among the members that room existed for some 
modification at least in the classification of their labours and inquiries ; 



190 



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especially when, as will soon be the case, it shall have assumed the propor- 
tions of a perennial association, instead of an annual convention. 

What is State Medicine ? Dr. Ordronaux, who introduced the subject, 
defined it as " the application of the principles of medical science to the 
administration of justice and the preservation of the public health ; a sys- 
tem of medical police, preventive, punitive, and reformative." Mr. Everett 
used for it the synonyme " State Hygiene." Dr. E. Harris, referring to 
the German term, Medicinal Polizei, designated it as " the work of the 
State in reference to questions of sanitary science." This is confirmed by 
the language used in the only systematic English work on the subject. H. 
W. Rumsey, in his "Essays on State Medicine," 1 speaks of their theme as 
" the Agenda of a State with regard to the public health." 

It may not be out of place to quote briefly the schedule of topics deemed 
by this able writer to be appropriate to State Medicine. These are : — 

"1. Subjects concerning which the State should direct Investigation : a. Sta- 
tistical ; b. Topographical ; c. Jurisprudential. 

"II. Practical arrangements for the personal safety and health of the people, 
requiring for their enforcement either direct or legislative enactments, or local 
institutions and regulations : a. Preventive ; b. Palliative measures. 

"III. Organized machinery, established bylaw, for carrying into effect the 
aforesaid inquiries, for deliberation and advice on special arrangements and 
emergencies, and for the administration of existing laws. This would compre- 
hend, a. The education of medical men, and the qualification of other technical, 
scientific and administrative agents, b. The institution of official authorities — 
Boards and Offices — for central and local superintendence and action." 

Obviously, a distinction may thus be properly maintained between, upon 
the one hand, the Science of etiology, and the Theory of public hygiene 
. — and, on the other, State agenda for the legislative and administrative 
application of such theory and science to the protection and amelioration 
of the public health. 

But, we must leave this topic, to dwell for a short time upon the report 
to the Sanitary Convention, by Dr. E. M. Snow, of Providence, on Regis- 
tration. 

Dr. Snow, in clear and concise language, states, I. The kind and extent 
of information desired for statistical and sanitary purposes ; and, II. The 
best method of obtaining the information needed, in relation to births, 
marriages and deaths, particularly in cities. 

Upon the first head, we have room to quote only the following para- 
graphs : — 

"Information in relation to the parentage of those who die is important, not 
only because the facts obtained relate to two classes of the population which, 
as classes, are entirely different from each other in their sanitary condition and 
in all the circumstances by which they are surrounded; but also because the 
division of the population according to nativity or birth-place has no value 
whatever, and only misleads and deceives the inquirer after truth. And yet the 
classification according to birth-place alone is given in the mortuary reports of 
all the cities of this country except Boston and Providence. 

"The following examples will show the value of this distinction. In the city 
of Providence, during the year 1859, there were 340 deaths of children under 5 
years of age. According to nativity, we find that 338 of these children were 
of American, and 2 only of foreign birth. But, classified according to paren- 
tage, 137 were of American, and 203 of foreign parentage. 

" In the same city, during the same year, there were 75 deaths from the four 



1 London, 1856. 



1861.] 



Sanitary Science. 



191 



diseases, cholera infantum, cholera morbus, diarrhoea and dysentery. Of these 
75 persons, 69 were of American and 6 of foreign birth; but according to 
parentage, 25 were of American and 50 of foreign parentage." 

In relation to the registration of births, the two plans, of requiring pa- 
rents to report them, and of demanding the same duty of physicians 
have proved practically inoperative. Dr. Snow believes the only available 
method to be, that of requiring the recording officer to obtain the informa- 
tion personally, or by his agents. This is done in Boston and Providence, 
with good results. In Providence, marshals are employed to visit every 
family in the city, in January and July of each year, and obtain all neces- 
sary information in regard to all children born during the preceding six 
months. A fee of ten cents for each full report of a birth, and another 
fee of the same for recording it, are provided. 

As to marriages, a plan similar to that contained in the Code Civil of 
France is recommended. According to this, a formal marriage contract 
must be written, signed, and sealed, acknowledged before a proper officer, 
and placed on record. The certificate to this effect of the recording officer 
can alone authorize the completion of a marriage by a religious ceremony. 

Equally imperative reasons are urged in this report in favour of an 
analogous provision for the registration of deaths. It is advised that, 

" 1. No dead body of a human being shall be buried, or placed in a tomb, or 
removed from the city, without a permit from the recording officer. 

" 2. No permit shall be given until full information concerning the deceased 
person is furnished, including satisfactory evidence in relation to the cause of 
death. 

" For the latter purpose, 'well qualified physicians should be appointed in all 
cities, whose duty it should be to make an examination into the circumstances 
relating to all deaths reported without the certificate of a physician or of a coro- 
ner.' " 

If we turn now to Mr. Rumsey's papers on the " Right Use of Records 
founded on Local Facts," it will appear that similar difficulties to those 
which impede the collection of sanitary statistics with us, are also obstruc- 
tive in England. Dr. Farr asserted recently that "only 83 in 100 of deaths 
throughout the kingdom are certified by medical attendants ; and that in 
one quarter of a year nearly twenty -two thousand deaths were returned with- 
out any authorized statement of the cause." 

In France, the law for registration of births, deaths, and marriages is 
precise. The medecins verificateurs of Paris are required to attest, after 
examination, the fact of death, its cause, and other particulars. In Prussia 
and the Southern German States, accuracy in the returns is not secured to 
any great extent. 

The Austrian system of mortuary registration is the most perfect. Every 
death must be examined into by the Todtenbeschauer, who is a surgeon. 
His certificate, founded on personal inspection and inquiry, is necessary to 
burial. All sudden, violent, or suspicious deaths, still-births in certain 
cases, and deaths under the treatment of quacks, are referred to a court of 
official physicians and surgeons. — Gerichtliche Leichenbeschau. 

The two papers to which we have just referred were contributed, as stated 
upon their title-page, by Mr. Rumsey, to the meeting of the National As- 
sociation for the Promotion of Social Science, at Bradford, England. This 
Association, organized in 1851, in which year its first meeting was held at 
Birmingham, under the Presidency of Lord Brougham, contains among its 
members a large number of the most eminent men in Great Britain. The 



192 



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Department of Public Health has been especially favoured in this respect ; 
the medical profession being largely represented amoug its members and 
committees. 

Mr. Rumsey's object appears to be the laudable one of promoting sani- 
tary reform by instituting more reliable methods for accumulating such 
facts as are required for the establishment of its principles ; by "the adop- 
tion of a more rational, trustworthy, and efficient system of public inquiry 
and record than has yet been applied to the sickness and mortality of the 
population." Only thus can the true laws of etiological science be ascer- 
tained. 

" If complete records of sickness and mortality were compiled and published, 
in the several registration districts, by a legally constituted order of men, of 
superior education and large medical experience, habituated to scientific pro- 
cesses, and in respectable position, any deliberate concealment or perversion of 

facts would be next to impossible Granting fully that it would be most 

unreasonable to look for perfect reports under any general system, yet, to oppose 
measures clearly tending to secure a minimum of error, because, in the nature 
of things, abstract truth is unattainable, I consider a culpable absurdity." 

John Bellers, at the beginning of the eighteenth century, Dr. Clifton, in 
1132, and Dr. Walker, of Huddersfield, in 1844, urged strongly a system 
of public registration of disease. Liddle, Milroy, and others, have followed 
with similar plans. Amongst those, who, in England, have recently taken 
active interest in the subject, have been Miss Louisa Twining, whose paper 
was presented to the Social Science Association in 1860, and Florence 
Nightingale, who made some valuable suggestions upon it to the Statistical 
Congress. 

The difference of opinion between Dr. Milroy and Mr. Rumsey as to the 
registration of sickness being placed under control of the Poor Law Board, 
to which the latter objects, does not immediately concern us ; although ex- 
perience in this country also would probably sustain the view that "pauper 
controlling authorities" are, by the very nature of their charge, nnfitted for 
wider spheres either of sanitary investigation or medical relief. 

Yet, commencing with cases under care of Guardians of the Poor, sta- 
tistics of dispensaries and hospitals might follow as well as those of prisons 
and penitentiaries ; asylums of different kinds ; dock -yards, arsenals, and 
other public works ; revenue departments and police force ; mines, collieries, 
factories, and public schools. Friendly or beneficial societies have fur- 
nished a great deal of material, already, to vital statisticians. Lastly, it 
only requires uniformity of record, and a public supply of tabular forms, as 
in the instance of the medical records of the army, to enable private prac- 
titioners to furnish full accounts of the statistics of disease and mortality 
occurring in the community at large. It is very much to be desired that 
such accurate and regular statements might take the place of the annual 
"Reports on Epidemics" of our county, State, and national associations ; 
which have been in this country, as they are said by Mr. Rumsey to have 
been in England, with few exceptions, "incomplete, unsystematic, and tem- 
porary." Such reports are mere apologies for the statistics which ought to 
he obtained for sanitary purposes, were the minds of medical men fully 
awake to their importance, and to the facility with which they might be 
recorded and collated. 

Many errors in sanitary, and even in medical, theory, might thus receive 
correction. Mr. Rumsey quotes, for example, the very diverse views of 
the late Dr. Snow, Dr. W.Budd, and others, upon the extension of cholera ; 



1861.] 



Sanitary Science. 



193 



of Drs. Murchison, Barker, and McWilliam, and of Dr. Parkin and Mr. 
Craig, of Ayr, upon the origin of typhus and typhoid fever ; to show that 
observers of the same facts may reach the most opposite conclusions, so 
long as those facts are not so exactly rendered as to allow of close scientific 
analysis. 

Again, two of the etiological propositions which have, from the high 
character of their advocates, as well as from their own practical bearing, 
attracted of late the most attention, are Dr. Farr's law of altitude, i. e., 
that the amount of disease and mortality varies inversely with elevation 
above the sea level; and Dr. Baly's law, that disease varies in proportion 
to the density of population. Now, both of these " laws" have been very 
firmly established by facts in regard to cholera, so far as cholera is concerned. 
But, we venture to affirm that it requires a much larger induction than has 
yet been made possible, to include all diseases under the same statements ; 
especially as there is a very simple view of the etiology of cholera, accord- 
ing to which it would not be legitimate to extend any conclusion based 
upon the history of its propagation, farther than to typhus, and to the 
probable mortality of all severe zymotic diseases. 

Sanitarians have begun to see that, however numerous are the evidences 
of the destructive influence of filth in its various forms, yet it is a fallacy 
to imagine it the sole cause of preventable disease; or that "public 
cleansing and the care of the public health are convertible terms." Food, 
drink, climate, occupation, privation, migration, ethnological characters, 
must all be considered. Dr. E. Headlam Greenhow truly asserts that 
"from looking too exclusively to certain obvious causes of mischief affect- 
ing the public health, the benefits realized from sanitary exertions have 
often failed to fulfil the hopes of their promoters or the expectations of the 
public." 

Still further, Neison, the distinguished statistician, was able to show, 
from materials derived from the " Friendly Societies," that the highest ratio 
of sickness is sometimes found associated with a favourable rate of mortality. 
Mr. Rumsey goes farther, and asserts a belief that " a diminution in the 
rate of mortality will be found to co-exist generally with an augmentation 
of the rate of sickness. 11 

" The real sanitary condition of a population is most correctly determined by 
summing up the periods during which persons of every age and sort suffer from 
disease, injury, or infirmity. The total ' sick time' measures the amount of disease. 
Medical records display its nature and causes. The number of deaths, accord- 
ing to sex and age, determines its intensity. Upon these stand-points every 
statistical inquiry respecting life and health ought to rest." 

" Now, as a necessary result of improvements in domestic management and 
medical treatment, and owing to the removal of those more virulent agents of 
destruction which, by sharp and decisive strokes, prematurely sever the thread 
of life, its duration has been lengthened in our great cities. But, at the same 
time, the sickly and infirm period of existence has been prolonged probably in a 
greater degree than even life itself. Chronic diseases, or at least functional 
disorders have increased. Yital force is lowered. Man's work is arrested; his 
duties are unperformed ; his purposes fail ; though he still lives. Weakly, dis- 
eased children are now mercifully helped, as they never were in olden time, to 
grow up into weakly, ailing adults, who, in their turn, propagate with abnormal 
fecundity an unsound progeny. Is this true sanitary progress ? Does it deserve 
the ostentatious parade of a decreasing death-rate?'*' 

Disheartening indeed would be the prospect to the well-wisher of man- 
kind, if this were the best result attainable in the application of the princi- 
No. LXXXIIL— July 1861. 13 



194 



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pies of private and public hygiene. There is a better side to the picture ; 
but still, it is highly important to take heed to the facts as they are, lest 
we should overlook means of improvement quite as necessary as any that 
have yet been discerned. 

We are compelled to forego the consideration of Mr. Rumsey's second 
paper, on " Certain Departments of Medico-Sanitary Police and Medico - 
Legal Inquiry ;" in which he conveys a plan for the establishment of four 
sanitary offices, statistical, supervisory, analytical, and medico-legal. His 
statement, however, therein, of the proper sphere and animus of the sani- 
tary reformer, may form an appropriate conclusion to these remarks : — 

" His motto is ' Progress.' His means : impartial, scientific, and comprehen- 
sive inquiry ; skilful compilation and truthful publication of facts in every 
district ; unsparing exposure of abuses ; systematic instruction of the people by 
qualified teachers ; enlightened administration of wise laws. 

" His ends : the health and longevity of the people, aiding their moral and 
religious improvement, confirming the obligations of social order, strengthening 
the foundations of public liberty, and thus promoting the lasting peace and hap- 
piness of his country." H. H. 



Art. XII. — A Treatise on Fever: or Selections from a Coarse of Lec- 
tures on Fever. Being part of a Course on the Theory and Practice of 
Medicine delivered by Robert D. Lyons, K. C. C, M. B. T. C. D., L. K. 
Q. C. P. L, L. R, C. S. L, M. R, I. A., Physician to Jervis-Street Hospi- 
tal ; formerly Clinical Assistant to the Meath Hospital ; Professor of 
Practice of Medicine and Pathology in the School of Medicine of the 
Catholic University of Ireland ; Foreign Secretary to the Pathological 
Society of Dublin ; M. R. M. S. Lisbon. Late Pathologist-in-Chief to 
the British Army in the Crimea, etc. etc. Philadelphia : Blanchard & 
Lea, 1861. 8vo. pp. 362. 

What is fever? what is inflammation? what relations do they sustain to 
each other? are questions which have been before the profession from the 
days of Hippocrates to our own, and which have not yet been satisfactorily 
answered. How many attempts have been made to define the words, how 
many have tried in vain to tell others exactly what they mean by them ! 
Different views have been given by different observers, each thinking that 
he was presenting the whole truth, when only one aspect of it had been 
offered. How characteristic this is of the human mind, when brought into 
contact with the vast and complicated works and doings of an Almighty 
Creator, to undertake giving a perfect description and explanation, by set- 
ting forth only such facts and appearances as can be embraced within its 
own narrow field of vision ! 

In the first chapter of the book before us, these same questions are pre- 
sented, and the light of the most recent researches and discoveries is thrown 
upon them. Our author is well qualified, from personal observation, and. 
from acquaintance with the doings and writings of German and French, as 
well as English pathologists, to discuss the subject which he has chosen for 
his treatise. He has practised in Ireland, that country of fever, he has 
practised "in the Crimea at the time of the extensive war in which such 
great countries," as England, France, and Russia, displayed all their re- 
sources. He spent some time at Lisbon, studying an epidemic of yellow 



1861.] 



Lyons, Treatise on Fever. 



195 



fever. He is familiar with the histories of epidemics to be found in the 
works of writers of all periods of medical history. He shows an acquaint- 
ance with the discoveries and views of Louis, Rokitansky, Yirchow, Schoen- 
lein, as well as of English, Irish, and Scotch observers, who have studied the 
disease at home and in the numerous colonies and dependencies of the British 
empire. He first calls attention to his own country, Ireland, as "the chief 
habitat of typhus fever." He quotes from the returns of the census com- 
missioners, that 222,027 persons had died of fever in Ireland within the ten 
years from 1841 to 1851. He mentions M. Scrive's calculation that the 
number of admissions for disease, in the French army hospitals of the Cri- 
mean war, amounted to 150,000, fevers and dysentery being the two prin- 
cipal diseases. And do we not find here a cogent reason for studying these 
maladies in the present situation of our own country ? 

In proceeding to inquire what fever is, Dr. Lyons adopts the definition 
of Cullen, as slightly modified by Dr. Christison, consisting in a brief enu- 
meration of the chief phenomena attending the outset of a fever case. 

" After a preliminary stage of languor, weakness, and defective appetite ; ac- 
celeration ol* the pulse, increased heat, great debility of the limbs, and disturb- 
ance of most of the functions, without primary local disease." 

One objection to be taken to this definition, or one deficiency in it, is 
that the cause is not noticed. Since the days of Cullen, our knowledge of 
the etiology of fever is decidedly advanced. We now recognize it as the 
effect of a poison, and this truth should be made prominent for its bearing 
on our treatment. A poison has been admitted to the blood, has acted on 
the nervous system, and various phenomena are the consequence. To be 
sure, there is not one poison, nor is there one fever. By typhus fever we 
mean the effect of an animal poison, by yellow fever that of a vegetable or 
telluric poison. 

It has always seemed to us, that Dr. Robert "Williams did good service 
by publishing a work on poisons; typhus fever, plague, dysentery, small- 
pox, and other diseases, being thus presented. If a definition be a sum- 
mary of phenomena suggestive of important points for the knowledge and 
treatment of a disease, its cause should not be excluded. 

Remarking on the definition thus adopted, Dr. Lyons very properly tells 
the student — 

" You have here a very good outline of the more ordinary characteristics of 
fever in its first invasion of the system, but you have withal learned but little 
that is of an absolutely positive nature; for, as we shall subsequently more fully 
see, there is but one of the phenomena here indicated which can be regarded as 
essential and constant." 

He then goes on to say — 

" If you ask me to name for you a character of fever which will stand the test 
of being invariable, constant, and so far essential to the pyrexial state, the most 
advanced researches of the most modern school of pathological inquirers can 
add nothing to the doctrine propounded by Galen, so long since as the second 
century of our era. This great observer asserted that the essence of fever con- 
sisted in a color pr aster naturam, or an increase of the animal temperature of 
the system to a degree greater than that of the physiological standard. The 
metaphorical significance of the terms applied to the disease from a very early 
period in the Greek, Latin, and other languages, implies the almost universal 
recognition of the condition of increased temperature in fever. Now the re- 
searches of modern chemistry seem to show that these names are in reality less 
metaphorical than they would at first sight appear to be. While, furthermore, 
it is proved that the animal temperature, whether in the physiological state of 



196 



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[July 



health, or in the pathological state of disease, is maintained by a true process of 
combustion, in no essential respect differing from that which takes place in any 
ordinary fire, or other agency consuming oxygen and generating artificial heat." 

The thermo metrical researches of modern observers are referred to, and 
cited to prove an increase of temperature, even when the patient complains 
of feeling cold. "We must admit, then, that, in the present state of medical 
science, an increase of temperature is essential to that state of the body 
known as the febrile. But, the word fever, besides its appropriation to 
designate a state of the body, is also used as a name of diseases. We have 
yellow fever, we have typhoid fever, and though a febrile state is charac- 
teristic of these diseases, it is not essential to them. At certain stages or 
periods of these diseases, it is generally absent, and we must sometimes ad- 
mit a patient to have had typhoid fever, though we have never recognized 
the febrile state, the increased temperature at any period of the disease. 
So, too, in inflammation, a febrile state is generally but not always found. 
The words lung fever, brain fever, show the connection in our minds be- 
tween fever and inflammation. Broussais and others were unwilling to 
recognize fever apart from inflammation. Now, however, all admit that 
typhoid fever and yellow fever, frequently attended by inflammation, as 
they may be, consist in something very different. But what is the precise 
meaning of these two words? We were told at one time that heat, red- 
ness, pain, and swelling were the phenomena of inflammation. Mr. Ben- 
nett would give these up, and drop the word inflammation, and speak only 
of exudation. The profession is not ready to go with him. We must 
admit that we cannot tell exactly what we mean by inflammation. It may 
take place without fever, which is almost never an inseparable accompani- 
ment at all stages of the processes. And, however frequently exudation 
may be found in the lungs, intestines, in the serous membranes of the bodies 
of those who have died with typhoid or bilious fever, we do not find appre- 
ciable alterations of the organs of all who fall victims to these diseases, al- 
though fever may have been a prominent symptom. We must use the words 
fever and inflammation. We cannot say exactly what we mean by them, 
and yet, too, we are learning more about them. Increased tissue change 
has some relation to these processes. We recognize that the source of the 
normal temperature is to be found in the chemical development of heat at- 
tendant on nutrient changes perpetually going on in the tissues. In lung 
fever, in typhoid fever, more heat is made at the expense of the body itself 
3?ood is not taken, the stomach cannot digest it; at the same time, there is 
call for fuel. Eisenman tells us of pyretogen, of fever stuff; the blood is 
loaded with carbon and hydrogen derived from a disintegration of tissues, 
the lungs and the heart are working more actively to introduce and circu- 
late the oxygen, and bring it in contact with the worn-out particles, and, 
thus, caloric is evolved. But what is the cause of this increased activity of 
r heat-making organs? The student sometimes gets rid of old papers from 
his study, whose presence is an inconvenience, by burning them up. Are 
these materials of the body which are being gotten rid off in a similar way ? 
A person is shut up in a room filled with exhalations from the bodies of 
several other persons, or he is exposed to emanations from a marsh, and 
presently we find the temperature of his body increased. A poison has 
gotten into his blood, processes analogous to those of fermentation are set 
up, we have a febrile movement. Sometimes one organ suffers particu- 
larly. A person is exposed to cold when the skin is active. There has 
been increased tissue change, and the skin is getting rid of worn-out parti- 
cles, and by cold these processes are arrested. The blood overcharged with 



1861.] 



Lyons, Treatise on Fever. 



19T 



effete material is driven to the lungs, and we may have diseases known as 
lung fever, as catarrhal fever ; or, a serous membrane may be the seat of 
the determination ; we may have a pleurisy, a pericarditis. Here we have 
inflammation. A peculiar poison gets into the blood ; after a while, a febrile 
movement is very apparent. There is a decided increase of temperature. 
The blood is determined to the skin ; we recognize heat, redness, pain, 
swelling, congestion, exudation. An eruptive fever is declared, and the 
febrile movement subsides, the usual temperature of the body is restored, 
the circulation ceases to be more active. But, does suppuration take place, 
are there pustules of the skin and mucous membrane, we have what is called 
the secondary fever of variola, effete matter is in the blood again, and is 
being burnt up, or otherwise gotten rid of by excretion. In rheumatism, 
also, we have fever and we have inflammation as effects of a poison ; and, 
at the same time, neither fever nor inflammation is essential to rheumatism. 
Now, a recognition of a poison as the cause of variola and of rheumatism 
is important for the pathology and therapeutics of those diseases ; and, 
whilst we commend Dr. Lyons for dwelling on increased tissue change, and 
elevated temperature, and quickened circulation, in their relation to fevers, 
we do not think that he dwells enough on the etiology of the diseases he 
is describing, absolutely or comparatively. He thus concludes his discussion 
of the nature of inflammation and fever : — 

" Fever is of general or systemic origin ; inflammation is essentially of local 
origin. Fever and inflammation are both characterized by increase of the animal 
temperature, increased metamorphosis of tissue, and increased circulation. 

"In fever these conditions are produced generally and simultaneously through- 
out the system ; in inflammation they are essentially local in their origin, and, if 
the inflammatory processes remain purely such, they may never even extend 
beyond the limits of the inflamed structures. In fever (purely such), the nutrient 
metamorphosis, though commonly attended with interstitial absorption, pro- 
gresses in both tissues and organs without injury to their structure, and, it may 
be, without interference with their functions. In inflammation, on the other 
hand, local change is induced, often to the extent of complete disorganization 
and destruction of tissue, with the result of organs being spoiled." 

This statement of the relations of fever to inflammation does not satisfy 
us. Let us distinguish between the different meanings of the word fever ; 
let us take the word as applied to a disease. Typhoid pneumonia, rheu- 
matic pericarditis — do not inflammation and fever meet in these terms ? 
How very rare are idiopathic pericarditis, gastritis, and peritonitis ! These 
diseases are almost unknown, except as produced by poisons which give 
rise to fevers. A rheumatic fever, a typhoid fever, a surgical fever, are 
attended by inflammation, when the poison in the blood is determined to 
the pericardium, to the lungs, to the intestines, to the peritoneum, and the 
tissue is unable to remove it. Sometimes, a hemorrhage, a diarrhoea, a 
profuse sweat, are the last phenomena of a fever ; the tissues seem to have 
been able to remove the poison from the economy. A patient often gets 
well of fever without inflammation. Sometimes, congestion of the viscera 
is the only post-mortem phenomenon. In fatal cases of typhoid fever, 
softening, ulceration, exudation of intestinal glands are so frequently found 
that the disease was once called dothinenteritis. Both fevers and inflamma- 
tions, then, are due to poisons affecting the blood and the nervous system, 
but these poisons do not always so interrupt the nutrition of organs and 
tissues as to give rise to the phenomena known as those of inflammation. 

But we have said enough of this difficult subject, of what may well be 
called a "vexed question," and we leave off with the same confession of 
imperfect acquaintance, of deficient knowledge with which we began. 



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Let us now say a word of the classification of fevers proposed by our 
author. He makes three great types — primary, irritative, and eruptive 
fevers. Under the latter, he places variola, rubeola, scarlatina, miliaria. 
We might ask why erysipelas, erythema, and urticaria are excluded from 
this association. These last diseases are attended with fever, are due to a 
poison, are general diseases, the skin being the part to which the poison 
seems especially determined. Other skin diseases, as lichen, may be deemed 
suitable for the same list; and, thus, at every step in nosology, we find evi- 
dences that we do not yet know the nature of diseases, and are not able to 
perfect a natural classification. 

Our author places as irritative fevers, gastric fever, gastro-intestinal, re- 
mittent, and hectic fever. But why should not this last be associated with 
surgical and puerperal fever ? Has not pygemia something to do with all 
of them ? In "typhoid fever," have we not reason to believe that secon- 
dary fever is sometimes set up from effete matter of the intestinal abscesses 
getting into the blood ? May we not profitably study typhoid fever at a 
certain stage in connection with variola, surgical fever, and puerperal fever ? 

Dr. Lyons divides primary fevers into three groups. In the first we have 
continued fevers, synocha, synochus, typhus, and typhoid. Must we not 
admit all these diseases to be from poisons ? Do we not know typhus 
fever to arise from exhalations from living bodies ? The names jail fever, 
camp fever, ship fever, show our belief of the origin of the disease in expo- 
sure to emanations from the skin and lungs of living men crowded together. 
Typhoid fever is not due to this poison ; it arises in country villages, in 
isolated houses ; it prevails amongst the rich as well as amongst the poor. 
We recognize these two diseases as distinct, not merely from symptoms 
and history, but also in their etiology. To be sure, we do not know what 
is the cause of typhoid fever. Is it a poison manufactured in drains and 
water-closets ? Is it taken into the system by drinking water from wells 
into which sewerage has penetrated ? Is it an animal poison, or can 
vegetable decomposition give rise to it ? What have telluric emanations 
to do with it ? Again, in the diseases known as typhus and typhoid fever, 
is there only one poison ? What do we mean by the typhus state of various 
diseases ? Is it not connected with the presence of effete matter of the 
body, being in the blood, and thus brought into contact with the nervous 
system ? A poison first may interfere with the functions of the nervous 
centres presiding over circulation, secretion, excretion, as well as with other 
organs, but in time new poisons are generated, or, rather, retained in the 
system, secretion and excretion being suspended. May we not thus account 
for similar symptoms and conditions in various fevers, as typhus, typhoid, 
surgical fever, erysipelas, puerperal fever, diphtheria ? But what is the 
cause of synocha and synochus ? Fatigue will give rise to fever. If the 
nervous system be exhausted by muscular exercise, by intellectual effort, by 
moral emotion, we may have a fever not caused by poisons from without, 
but by poisons resulting from imperfect excretion. Besides, too, we probably 
have a good many telluric, vegetable, and animal poisons which singly, or 
in combination, give rise to various fevers. We cannot handle these poisons, 
we cannot analyze them ; and Dr. Lyons seems to us wise in retaining the 
old terms synocha and synochus, and in trying to find out what was meant 
by them, in trying to give us more definite ideas about them. He tells us 
also about febricula and relapsing fever, but he does not say anything about 
the plague, the relations of which to typhus fever should be brought forward 
in every scientific treatise on fevers. What connection has this formidable 
epidemic with intermittent and remittent fevers? Does it proceed from an 



1861.] 



Lyons, Treatise on Fever. 



199 



animal, a vegetable, a telluric poison, or from a combination of the three ? 
Here we have one of the defects of the classification adopted by Dr. Lyons, 
etiology not being allowed its due influence. Thus, yellow fever is classed 
amongst remittent fevers, and is not distinguished from bilious fever ; and 
the general characters of the three great groups of the primary, the irri- 
tative, and the eruptive fevers, given in the chapter on the classification of 
fevers, are not to us satisfactory. Thus, our author tells us — 

" That primary fevers are essentially characterized by the development of a 
general pyrexial state, independent of specific pathological lesion, and having 
no necessary connection with localized disease in any portion of the body, or 
in any organ or tissue. All organs, and perhaps all tissues, participate in the 
febrile action, when once it is established ; but it cannot be said to originate in 
any one part more than in another, saving so far that the considerations already 
adduced show that the first link in the chain of morbid actions may be found 
to implicate the nervous system. 

" The irritative fevers, on the other hand, owe their existence to lesion of a 
well-defined kind in particular parts of the system. They have a true anatomical 
seat, or origin, and are to be regarded as the constitutional expression of localized 
disease. 

"While, therefore, the primary fevers are independent of all localized diseased 
processes, and are commonly to be met with unattended by pathological changes 
of any kind, the irritative fevers recognize no existence independent of local 
disease of some kind. 

" The eruptive fevers are characterized by the absence of all specific lesions 
of the more important viscera, while the cutaneous surface is so frequently the 
seat of pathological processes in these fevers that, in the majority of instances, 
our diagnosis between the individual fevers of this group depends on the special 
character of the rash or eruption presented on the skin." 

Now we must maintain that typhus and typhoid fever are characterized 
by lesions, in the same way, though not to the same degree, as are scarlet 
fever, measles, and smallpox. All of these diseases are general, constitu- 
tional. No one of them consists in the lesion of any one organ or tissue. 
Two hundred and eighty-seven pages of the first volume of M. Louis' work 
on typhoid fever are devoted to pathological anatomy. Whilst there is 
scarcely an organ or tissue of the body which may not be affected by the 
disease, the intestinal glands are almost always the seat of changes. In 
typhus fever the lungs are very often the seat of important lesions. In 
scarlet fever the skin, the throat, the kidneys, are especially the seat of 
changes. In measles the mucous membranes of the lungs and eyes are suf- 
fering parts. And in hectic fever, or surgical fever, or rheumatic fever, a 
poison, generated in the system itself, disturbs the innervation and circula- 
tion, gives rise to general symptoms, and, secondarily, to lesions of particu- 
lar parts or organs. All these diseases are due to poisons ; all these poi- 
sons acting on the blood and nervous matter provoke efforts of nature to 
expel them from the system, and the great emunctories of the economy, the 
skin, the liver, the lungs, the intestinal glandular system, suffer from an 
especial determination of the poison to one or more of them. We know 
of arsenic, of corrosive sublimate, of strychnia, of opium, that each is 
determined to certain parts or organs. The salivary glands free the econ- 
omy of one poison, the kidneys of another. And we recognize the same 
truth in this case of the impalpable animal, vegetable, and telluric poisons. 
Opium and the typhus poison both act on the cerebral hemispheres; strych- 
nia and the poison of hydrophobia are determined to the spinal marrow ; 
but the words encephalitis and myelitis are not applicable in any of such 
cases. There is a suppurating wound; there are minute abscesses in pus- 
tules of smallpox; fever sets in, but it is not to be regarded simply as "the 



200 



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[July 



constitutional exponent of specific disease." This secondary fever is from 
a poison acting first on the blood and on the nervous system. 

But we have perhaps said enough to show why we object to the classifi- 
cation of our author, and to set forth our own ideas of the propriety of 
arranging fevers as all arising from poisons, of most of which, to be sure, 
we know nothing beyond their effects on the human body. 

In the fourth chapter of the book under review we find a good account 
of simple continued fevers. We like what our author says of bloodletting 
in synocha. He has been speaking of fever implying increased action in 
all parts of the system, and the production of a great quantity of effete 
material resulting from the increased metamorphosis of the tissues. He 
then goes on to say : — 

"Under these circumstances, the course of the blood surcharged with the 
effete materials produced by the consumption of the tissues in fevers, may be 
compared to a stream, which, impregnated with earthy particles, silt, and other 
impurities, deposits them in various points of its course, and then flows on pure 
and limpid. Such analogies as these, however, must not be pushed too far; the 
lungs eliminating carbon and hydrogen ; the skin throwing off water, salts, am- 
monia, and other compounds ; the kidneys carrying off urea, uric acid, chlorides, 
sulphur, phosphates and their allied bases, and the intestinal canal acting as the 
common-sewer of the system, play the part of so many strainers or purifiers. 
"We must not forget, however, that in a highly complicated machine like the 
animal body, each part reacts upon all the others, and the blood itself, when 
rendered impure, will in its turn influence the nervous centres, which stimulate 
the vascular system and the other parts engaged in the febrile processes. It is 
under this view that venesection may be defended when employed with the object 
of lessening the amount of stimulant fluid, 'impure fluid,' which is reacting on 
the nervous centres, and thus adding fuel to the fire, and keeping up the cycle 
of pyrexial actions. We do not deny, then, that there are cases in which a bold 
and early venesection may have the effect of partially arresting the process of 
febrile actions, or of preventing them from spreading to a wider circle of parts. 
Mark, however, that in this aspect, bleeding answers but one purpose; it may 
control, but it cannot cure the fever. Febrile action, if continued only for one 
hour, produces effete material, as the burning of coal or wood produces ashes. 
The pathological or febrile ashes must be eliminated from the system ; bleeding 
cannot in any conceivable way effect this object; it can only be accomplished 
by elimination through the pulmonary surface, the skin, the intestines, or the 
kidneys, acting singly or in combination." 

Considerations like these may well be impressed on the mind of the stu- 
dent. We study the natural terminations of fever, lysis and crisis, to get 
indications of treatment. We find nature acting to get rid of poisons, 
sometimes gently and imperceptibly, and sometimes convalescence dates 
from some violent effort. Can we by emetics, cathartics, sudorifics, or bleed- 
ing, get rid of the poison when its first effects are noticed? Can we break 
up a fever? Dr. Jackson, of Boston, in his last letter to a young physician, 
has avowed his belief that an emetic will sometimes act to interrupt pyrex- 
ial action, and that its administration will sometimes be followed by prompt 
convalescence. He also calls attention to the fact that but seldom has the 
physician an opportunity of using this means. Fever begins so insidiously, 
its early symptoms are so uncertain, that we are seldom called to take charge 
of a case till the poison is thoroughly incorporated in the system. Dr. 
Lyons tells us — 

"There can be no doubt that a strong emetic of the potassio-tartrate of anti- 
mony, sulphate of zinc, ipecacuanha, or mustard, may give a powerful revulsion 
to the nervous system through the gastric filaments of the vagi, and it may be 
that in the minor febrile states it will be found possible to arrest the pyrexial 
action by such means." 



1861.] 



Lyons, Treatise on Fever. 



201 



"It will be in the recollection of almost every practical physician, that he has 
seen cases in which obstinate gastric irritation, and incapacity of retaining food 
or medicine have been directly traceable to the abuse of the emetic treatment 
of fevers." 

So, too, in the rise of purgatives. Some practitioners look to purgation 
as only next in importance to bleeding. 

" The Hamiltonian method once took the place of the hydropathic system of 
the present day; the one insisted as strongly upon the all sufficiency of intestinal 
elimination as the other upon that through the skin. Cases will undoubtedly 
occur in which purgation is the most obvious as well as necessary therapeutic 
indication to be followed in the first instance ; but no practitioner of any expe- 
rience can have failed to meet with cases in which excessive purgation has 
been productive of the most injurious effects." 

With regard to sudorifics and sweating as a means to free the system 
from poison, the language of Sydenham is quoted that only those sweats 
which are the result of coction or digestion of the materia morbifica are 
available for crisis. 

"All practical physicians must be aware of the fact that sweating is not in- 
frequently a symptom of most unfavourable augury in all kinds of fevers." 
" Sweating cannot be regarded as a curative process perse, and is to be regarded 
as a safe and reliable therapeutic and curative process only when it forms part 
of a general eliminative action in the system." 

We have thus cited passages from our author to show how he looks 
upon the eliminative treatment of fever. He would appeal gently to the 
various emunctories, as, in each case there may be a special indication of 
the propriety of quickening the activity of one of these organs. But some 
of the fever poisons seem so directly determined to nervous centres of 
organic or animal life, that at all times one of the nicest questions in the 
treatment of fevers has been as to the use of stimulus. Leeches to the 
temples, cold lotions and showerings, are, to be sure, especially indicated in 
synocha. Our author agrees with Dr. Jackson in deprecating bleeding 
from the temporal artery. The ice cup applied on the shaven crown is 
called a most excellent remedy for severe cases. A proper discrimination 
is made between the cerebral symptoms of synocha and those of typhus. 
In these latter cases the poison weighs upon the nervous centres of secretion 
and excretion, the blood is thronged with effete matter which is to be gotten 
rid of only by stimulating the circulation and the emunctories. Though 
meningitis and encephalitis are simulated and threatened in synocha, the 
-congestion of typhus is a very different matter, and must be very differently 
treated. The fact of typhus frequently proving fatal by cerebral compli- 
cations in the better class of society, as constantly as by thoracic secondary 
lesions amongst the lower classes, is properly dwelt upon. That state of 
cerebral and nervous excitement resembling the condition of delirium tre- 
mens, is also noticed, as well as the delirium ferox, the high excitement, 
with violent muscular efforts, sometimes suddenly succeeded by profound 
prostration and collapse, or by coma, stertorous breathing, and relaxed 
sphincters. Now these cases are not to be treated as brain fevers. Dr. 
Lyons says : — 

" Numerous dissections warrant me in stating that I have found sensible con- 
gestion of the brain and its membranes with increased serosity in the ventricles 
and subarachnoid spaces in cases which had presented no cerebral symptoms 
whatever during life ; and again, that where there had been delirium ferox, and 
even in more than one instance, coma, no appreciable lesion could be detected 
in the brain or spinal cord after the patient's death. Many of the cerebral 



202 



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[July 



symptoms in typhus are explicable on the supposition that they are caused by 
a temporary congestion of the introcranial vessels ; others, it is equally probable, 
are due to diminished nutrition of the brain, from its receiving an impure and 
inadequate supply of blood. A third class of cases, including those with coma- 
tose and paralytic symptoms, may be traced to the influence of the highly car- 
bonized and otherwise deteriorated blood which is sent to the brain and spinal 
cord." 

Now, all these considerations are eminently practical. And we are glad 
to see how much and how well our author discourses on treatment. The 
word self-limited has been applied to fevers, and with some truth ; but 
certainly there are no diseases which so task the skill of the physician, or 
in which, by doing or letting alone at the proper moment, so much can be 
done to contribute to a favourable issue. Regimen and drugs are not more 
valuable in any diseases than in fevers ; nor are powers of observation and 
reasoning, discretion and common sense, in medical attendants, of more use 
in any other class of cases. This very question of stimulus, when to give 
and what to give, is a difficult one. We believe the blood, to be loaded 
with effete hydro-carbonaceous products. Shall we introduce these same 
elements in alcoholic and vinous drinks ? The brain is already congested 
— shall we give opium ? And we cannot reason out these problems. We 
are not so thoroughly conversant with all the processes of fever as to enable 
us to tell positively that such a drug in such an application will act favour- 
ably in a given case. We cannot yet establish a routine practice. Each 
author can only describe such varieties in the affection of different organs 
and tissues as have fallen under his notice, and say what in his hands has 
worked favourably. Dr. Lyons properly brings forward, as the result of 
his observation, "that cases in which the action of the system is uniform 
and well-balanced in all the organs and functions, may be regarded as com- 
paratively safe ; those, on the other hand, in which there is an excessive 
preponderance of one set of actions, must be viewed with suspicion, if not 
alarm. While all parts of the machine are working with uniform pressure, 
though at a high velocity, its safety is not immediately endangered." Here 
we have considerations to decide us in our treatment. We must not inter- 
fere to disturb regular and proportionate efforts of nature, but where the 
nervous system or the constitution is being overwhelmed, we may try to 
appeal to one or other of the emunctories. We may administer such arti- 
cles as will rouse the nervous system or the constitution to throw off what 
otherwise would depress them beyond recovery. 

The combination of tartar emetic and opium, brought forward by Dr. 
Graves, when the brain especially suffers, the exhibition of a mustard 
emetic when the lungs are especially oppressed, turpentine in typhus bron- 
chitis, grain doses of calomel with opium, all these and other remedies are 
brought before the student with a judicious discussion of the circumstances 
under which they may be used. He is told that the physician at the bedside 
of a typhus patient "is in the position of a captain of a ship, who skilfully 
makes his vessel ride out the storm, not by any one specific mode of action, 
but by a combination of skill, intrepidity, and readiness, which enables him 
to see at once every possible source of danger, and to use every means at his 
command to obviate it." 

We are glad to see a number of illustrative cases, of brief histories and 
post-mortem appearances. The author's observations have been in various 
localities, amidst various circumstances of climate, regimen, and race. He 
calls attention to Comparative Pathology. He remarks on the dissimilar 
types of febrile disease developed amongst the armies engaged in the Cri- 



1861.] 



Lyons, Treatise on Fever. 



203 



mean war. Synocha, with high pyrexial action requiring bleeding, was 
prevalent amongst the Sardinians, whilst in the English, French, and Rus- 
sian camps "putrid types of fever prevailed, in which stimulants were urgently 
called for." A sweating fever, with foul emanations from the skin, pre- 
vailed amongst the Turks, we are told, also. 

"I have myself formed the notion, but I in no way insist on it as a well 
grounded hypothesis, that the sthenic or synochal types of fever are in the 
present day, and, perhaps, have always been, most remarkably developed 
amongst the graminivorous and herbivorous races of men, while the putrid or 
typhus types of febrile action more readily develop themselves in the races 
amongst which animal food constitutes a large part of their ordinary aliment." 

We have a good deal yet to learn about typhoid fever, its epidemic and 
climacteric variations, as well as those suggested in the paragraph which 
has just been cited. We welcome, therefore, what Dr. Lyons has to tell 
us of this disease in the Crimea. M. Felix Jacquot prepared a valuable 
treatise on the typhus of the eastern army, which was published after the 
author's death. 

The Committee on Epidemics of the American Medical Association is 
collecting valuable materials for a scientific account of the fevers in this 
country. The first question is, what is typhoid poison, what is its origin ? 
and, then, how do atmospherical climacteric peculiarities, how do peculiari- 
ties of occupation, regimen, and constitution modify the activity of the 
poison ? Why in certain cases is it determined to the lungs, why in others 
to the brain ? Why does yellow fever so generally affect the liver and the 
gastric mucous membrane ? We find some information on all these points 
in the book before us. 

But we have lingered quite long enough over its first chapters. Yellow 
fever is the subject of the ninth chapter, and of the two following. The 
disease was observed at Lisbon during the latter half of the year 1857, 
when an epidemic prevailed in that city. 1 These chapters are chiefly valua- 
ble for the history of that epidemic on which they are based. Dr. Lyons 
does not allude to Dr. La Roche's work, which should be regarded as the 
standard treatise on the disease, containing so full a summary of whatever 
had been observed or written on this subject to the date of its publication, 
with a great deal of original valuable matter. We do not find any reference 
to Dr. Clark's edition of Dr. Bartlett's work on fevers, and we are very 
much surprised that such thorough, well digested, and valuable treatises 
should not be recognized by the Professor of the Practice of Medicine and 
Pathology of the Roman Catholic University of Ireland. 

We have already objected to yellow fever being classed amongst remittent 
fevers. The symptoms of the disease vary very much, making it even diffi- 
cult of recognition, and requiring the adoption of forms or groups in a 
description. Dr. La Roche prefers the division adopted by Dr. Wilson, 
who speaks of an inflammatory and congestive form, each subdivided into 
three grades. The inflammatory and congestive varieties, the typhoid, the 
malignant, the cold form were proposed by Dr. Jackson, and adopted by 
Dr. Copeland. Dr. Lyons remarks very properly — ■ 

" I can have no doubt that a great deal of the discrepancy of statement and 
conflict of opinion in the accounts we possess of the several epidemics of yellow 
fever occurring in various localities, has arisen from the different forms which 
the disease presents, being confounded in one common description, embracing 
the phenomena of all." 

1 See No. of this Journal for April, 1861, p. 480. 



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[July 



The five forms under which the disease is described by our author are, 
the algid, the sthenic, the hemorrhagic, the purpuric, the typhus. It is a 
little curious that the first form of a "fever," of which disease increased 
temperature is considered by many as the one characteristic feature, should 
be the algid characterized by a diminution, sometimes of as much as two 
degrees, in the animal temperature. This phenomenon is, to be sure, in 
accordance with what is offered in the cold stage of intermittent and remit- 
tent fevers.: and in the algid forms of those diseases, and in poisoning by 
arsenic and corrosive sublimate, a febrile movement is sometimes amongst 
the symptoms; and, sometimes, the skin is cold and clammy, the extremities 
are cold, the calorifacient processes being oppressed by the poison. 

This algid form, during the Lisbon epidemic, occurred most frequently 
in persons of the very lowest classes, but was not limited to either sex or 
to any age ; old and young alike being amongst its victims. The prostra- 
tion of strength was early and extreme, and the hemorrhagic tendency 
present to the most marked degree in a very large proportion of cases. 
This we should expect from the connection observed between diminished 
temperature and loss of blood. 

Dr. Lyons gives an interesting table of pulse-rate and temperature, in 
his remarks on the "sthenic" form, and thus shows that the highest pulse- 
rate and highest temperature did not correspond, and that there was no 
constant uniformity of relation between the two sets of phenomena. In 
sthenic cases there is a remarkable elevation of the temperature from the 
outset, an increase of three, four, or five degrees being common, and that 
of nearly seven having been observed. How great the difference between 
these two forms, the sthenic and the algid, as revealed in these accounts of 
the temperature of the bodies of patients classed under the two heads ! 

The cases under the hemorrhagic form are those which, next to what 
were classed under the algid, present the most " characteristic, appalling, 
and impressive features of the disease." Our author dwells on "the special 
and highly characteristic physiognomy" of yellow fever, the salient features 
of which are readily recognizable and taken in by the practised eye at a 
glance ; and he goes on to say : — 

" I must avow, after a very extensive experience of the worst forms of epi- 
demic disease at home and in foreign countries, and at the seat of war, that I 
have seen few assemblages of symptoms of a more striking, and, indeed, horrify- 
ing, character than those often presented in yellow fever cases, nor any in which 
more impressive feelings are called forth in the reflecting mind." 

In a single case, there was hemorrhage from the eyelids, nose, gums, 
tongue, stomach, intestines, and blistered surfaces. 

" The constantly fatal character of this form of the fever is pointed out, as 
well as the fact that death seems to take place in many instances directly as 
the result of the hemorrhages, and generally within from twenty-four to thirty- 
six hours after they have set in." 

Under the purpuric form, cases are designated in which the pyrexial 
state was well marked in connection with spots and patches of purpura. 
These were frequent in algid cases. One case is referred to in which the 
temperature was above the normal standard when the pulse had fallen to 
fifty-two, and the patches were precisely similar to those so often seen in 
the epidemic purpura hemorrhagica of Ireland. 

In only a few cases were typhus phenomena observed. These were pre- 
sented "in two orders of combination." In one they appeared as the 
primary and essential characteristics from an early period of the febrile 



1861.] 



Lyons, Treatise on Fever. 



205 



invasion, such cases resembling those of typhoid pneumonia, with jaundice. 
In other cases the patient passed through the sthenic or hemorrhagic 
forms, which were supplanted by the typhus. There was an increase of 
temperature in these cases to an extent of four or five degrees ; they proved 
fatal, and no follicular lesion was detected in any of them after careful 
examination. 

In reference to Dr. Clark's views of the connection of cerebral symptoms 
and black vomit with congestion and imperfect action of the kidneys, we have 
looked with interest at what our author has to say on the renal function. 

" Almost complete suppression was observed in certain cases. In other in- 
stances, and this not unfrequently, the urine has been abundant, normal in 
specific gravity and reaction, at times high-coloured, of a rich straw or amber 
colour, at times highly loaded with lithates, and presenting the brick-dust sedi- 
ment with more or less colouring matter in different cases. Under other condi- 
tions, the urine is found coagulable by heat and nitric acid, and it is occasionally 
brownish-red, smoke-coloured, or variously tinged, from more or less admixture 
of blood elements. No deficiency of any of the normal constituents of the 
urine was observed by me in any single instance, where there was not a total 
or partial suppression of this secretion, which seems to stand in very intelligible 
relation with the generally depressed condition of the vital powers and the 
stagnation of the circulation more especially, and was only one of several similar 
states of suspended action in the system. In a few instances, albumen was 
found in the urine in connection with this depressed condition of the circulation. 

" On referring to the results of the post-mortem examinations in yellow fever 
cases, it will be found that congestion of the kidneys, in common with most 
other internal organs, was sufficiently often observed." 

A little further on, our author speaks of urine with high specific gravity 
and with more or less abundant deposits of variously coloured lithates, as 
constantly attending the well-marked pyrexia of the sthenic cases, and of 
the same peculiarities being found in cases classed as hemorrhagic. The 
excretion of colouring matter having the usual biliary reaction was often 
observed in connection with pyrexial and apyrexial states. Parotitis, an 
efflorescent rash, bloody furuncles, are among the symptoms of yellow fever 
at which we look when we ask to what parts or glands is the poison espe- 
cially determined. 

" The state of the liver was the most remarkable, the most constant, and, to 
my mind, the most inexplicable condition presented in the post-mortem examina- 
tion of fatal yellow fever cases. I believe that it may be affirmed that some 
departure from the normal state of the organ was an absolutely .constant condi- 
tion in all cases which proved fatal. It was not only so with regard to the cases 
" examined by myself, but the concurrent testimony of all my learned confreres 
in Lisbon pointed to the same result. The colour most frequently presented was 
that of a rich fawn yellow, or buff, various shades being observable in different 
cases." 

M. Louis tells us also of the epidemic at Gibraltar — 

"That the most remarkable lesion of the liver was the alteration of its colour, 
which was more or less exactly the same in all the cases, and through the whole 
extent of the organ. This alteration consisted in a discoloration, the liver 
being sometimes of the colour of fresh butter, sometimes of a straw colour, 
sometimes of the colour of coffee and milk, sometimes of a yellowish gum 
colour, or a mustard colour, or finally, sometimes an orange inpistachie colour." 
"In the present state of science it seems to me impossible to determine the na- 
ture of this alteration." 

Dr. Lyons made microscopic examinations of the hepatic tissue, and the 
hepatic cells were found filled with globular oily and fatty matter. The 



206 



Reviews. 



[July 



natural appearance of the cell was completely altered, its outlines obscured 
and its nucleus rendered invisible. Dr. Alonzo Clark, of New York, in 
1852 found on microscopical examination of a yellow fever liver "a fatty 
state of all the secreting tube-cells, and such an abundance of free oil-glo- 
bules of large and small size, as to cover and obscure every thin section 
which was made of the liver," and asked the question, "is not the change 
so constantly observed in the livers of those dying of fatty fever an acute 
fatty degeneration ? Dr. Lyons has also inquired into the specific gravity 
of the liver, and gives a table of twenty-four cases from which there is 
shown a general correspondence between fatty degeneration and low spe- 
cific gravity, and that the specific gravity is a more accurate measure of 
the fatty change than that furnished by the colour of the hepatic substance. 
In ten cases an attempt was made to determine the absolute quantity of 
fatty matter by maceration of known quantities in sulphuric ether. Proof 
was thus obtained that with the yellow, or buff-coloured, or even the choco- 
late-coloured state of the hepatic substance, there was found a considerable, 
and in some instances a very marked increase of the fatty elements. 

In the eleventh and last chapter, marked as supplementary, there is given 
a summary of the chief climatological and other elements determined in 
connection with the Lisbon epidemic of 185T, extracted from an official 
report to the President of the General Board of Health at Lisbon. After 
careful inquiry in all directions no evidence was found to warrant the con- 
clusion that the "importation theory was even moderately well founded," 
though a belief in it was widespread and general, and not confined to any 
class of the community. 

" All parts of the city largely attacked by the epidemic presented in common 
certain conditions of insalubrity, which may be classed as follows: a. Defective 
water supply, b. Total absence of. or extremely deficient sewerage, c. Total 
absence or incompleteness of house-drains, privies, and a consequently unclean 
state of the streets, d. Badly-constructed dwellings, with deficiency of light 
and air, and want of thorough ventilation, e. Absence or defective condition 
of tertiary and secondary sewers." 

Thus we have additional proof of the great importance of effective sewer- 
age and of an abundant supply of water to the health of cities. There 
was no proof of contagion and no general belief in it. From 20 to 40,000 
of the inhabitants ran away from the foci of infection, but 

"Devoted attention to the sick was the universal rule with all classes of 
society; and even on the friendless and the stranger I have seen all the care 
and anxious solicitude bestowed that could be lavished on the nearest and the 
dearest friend or relation." 

"An excellent tranquillizing effect was produced on the public mind by the 
truthful and highly creditable manner in which the daily bulletins, giving a 
statement of the progress of the epidemic, were published by the authorities." 

The meteorological conditions at the outbreak and during the prevalence 
of the epidemic are discussed at some length, and we are told that — 

"So far as the available data can be relied on, there is no evidence of any 
very unusual atmospheric disturbances having preceded the outbreak of the 
epidemic ; nor again, during the months in which the epidemic reigned, is there 
to be recognized any very extraordinary departure from the meteorological con- 
ditions of the same months in former years." 

"The dew-point for November and December was remarkably high, 54.5 and 
50 as compared with 49.2 and 46.15, the highest respectively in any of the pre- 
ceding years. There is, however, no absolute relation between high dew-point 
and the epidemic outbreak in the preceding months." 



1861.] 



Kolliker, Human Microscopic Anatomy. 



20T 



We have thus endeavoured to give our readers an idea of the contents of 
the volume under review, and they will probably agree with us that it con- 
stitutes a valuable addition to our medical literature — that it is a book 
which is wanted, notwithstanding that so many treatises and histories of 
the subjects of the work have already been published. It is not an elaborate 
scientific treatise, gotten up and written with the skill and carefulness cha- 
racteristic of the books prepared by Dr. Bartlett and Dr. La Roche. It 
is, however, a very interesting and a very readable book. It conveys a 
great deal of valuable information, and supplies a want which has been felt 
of a succinct and satisfactory statement of the application of the views and 
discoveries of recent writers on physiology and pathology to the various 
fevers, in the treatment of which, as well as in prophylaxis, the practising 
physician feels so much the want of more light and of greater certainty. 

G. C. S. 



Art. XIII. — A Manual of Human Microscopic Anatomy. By A. Kol- 
liker, Prof, of Anat. and Physiol, in the Univ. of Wiirzburg. With 
219 illustrations. London, J.'W. Parker & Son, 1860. 

The name of Professor Kolliker has long been identified with microsco- 
pical anatomy, and most of our readers are familiar with the English trans- 
lation of the first German edition, issued in 1853-4, under the auspices of 
the old Sydenham Society, and republished in this country in 1854. Since 
that period two German editions have appeared : one in 1855, and one in 
1859. The present English version, we are told, "is, in the main, a con- 
densed version of the second German edition (of 1855). But every mate- 
rial addition that has been made to human microscopical anatomy, up to 
the present date, will be found incorporated in -it. The book is, therefore, 
brought well up to the third German edition — that of 1859." 

The mere issue of a new edition of a work so well known would require 
no more than a bare notice at our hands, were it not that it contains a 
frank acknowledgment of the accuracy of certain new histological facts of 
the highest doctrinal importance at the present time. 

Those who have been interested in the gradual development of the cell- 
doctrine, and who have watched the complete revolution it has recently 
undergone in the hands of such men as Bemak, Beichert, and above all of 
Tirchow, will remember well that the general idea underlying the histo- 
genetic doctrines of the earlier editions of Kolliker's Manual, was an ac- 
knowledgment of Schwann's theory of free-cell-formation. In fact, though 
an independent observer of the highest order, a careful perusal of these 
earlier editions shows that Kolliker was in many respects a disciple of 
Schwann, in his doctrinal ideas. Like Schwann, he saw in the fluid or 
semi-solid intercellular material the cyto-blastema out of whose plastic 
substance the cells had been produced; and while stubborn facts compelled 
him to admit that " botany knows no free cell development," and that 
" free cell development is in man and the higher animals far less common 
than has been hitherto assumed," he yet believed Schwann's theory to be 
applicable to " the development of the chyle and lymph corpuscles, of the 
cells of certain glandular secretions (spermatic cells, ova), and gland-like 
organs (closed follicles of the intestine, lymph glands, splenic corpuscles 
and pulp, thymus) ; lastly, of the cellular elements of the pregnant uterus, 



208 



Reviews. 



[July 



in the corpus luteum, in the medulla of foetal bones, and in the soft ossify- 
ing blastemata." When in addition to this long list it is remembered that 
Kolliker believed that " in fact all pathological cell-formation properly 
comes under this head," it will be understood that Schwann's doctrine 
played a large part in his notion of the process by which tissues are pro- 
duced. 

So well has this been appreciated that many of those who, without per- 
sonally investigating the subject, have opposed the teachings of Yirchow 
and his school, have relied on Kolliker as a strong authority against the 
new views, and more than one recent publication has rejected the progres- 
sive ideas, and clung to the old doctrines, reposing on Kolliker's work for 
their justification. 

But while a motley host of quill-drivers were beating back the wave of 
progress as best they might, the little band of practical microscopists who 
submitted Yirchow's new law " omnis cellula ex cellula" to the test of actual 
observation, were one by one won over to his side. Among these converts 
we now find Kolliker. 

The present English edition of his " Manual" is issued under his own 
supervision at his own instance, for reasons set forth in its preface by him- 
self. The modifications in views are therefore his own, and not the botch 
work of any meddling editor. And of these modifications we have first to 
notice an utter renunciation of that theory of free- cell development which 
has made the name of Schwann so famous. 

Let our author speak for himself. 

" \ 9. Formation of Cells. — With regard to the formation of cells, a dis- 
tinction has hitherto been made between the free origin of them, and their pro- 
duction through the intervention of other cells. The farther, however, investi- 
gation is prosecuted, the occurrence of a free cell-formation becomes more and 
more doubtful ; and it appears that all animal cells only arise, as in plants, in 
dependence upon other pre-existing cells. In this process of cell-multiplication, 
it is pre-existing cells which either produce secondary cells, as they are called, 
or multiply by division — endogenous cell-formation, and cell-formation by divi- 
sion. The cell-nuclei always play a very essential part in the multiplication of 
cells, and appear as the proper centres of formation for their evolution. 

" Whilst Schwann, in animals, in contradistinction to plants, regarded the 
free cell-formation as being the more frequent — that by the intervention of other 
cells, more as the exception — observers are now coming more and more to the 
conclusion that even in this respect animals and plants agree. As for me, I have 
already long since shown (Entw. d. Cephal, 1844- ; Ann. d. sc. Nat., 1846) that 
in embryos all the tissues are built up of the descendants of the cells which have 
arisen after the cleaving of the yelk ; and that even in the adult, in the most 
widely-distributed tissues consisting of cells, as in cartilages and in horn, free 
nuclei nowhere occur. Accordingly, I found myself constrained, in the first 
edition of my German Handbook of Histology, to limit the free cell-formation 
very much. Quite recently, Virchow (in Beit, zur Spec. Path. u. Therapie, 
1854, p. 329) has made known aperies of facts, from the department of patholo- 
gical anatomy, which show that in many places where formerly a free cell-forma- 
tion was admitted, it does not occur. If to these facts are added the new ob- 
servations of Virchow, with regard to the development of bones, as well as the 
recent investigations into the formation of the lymph-corpuscles, ive may indeed 
conclude that a free formation of cells does not anywhere exist." (p. 16.) 

It will thus be seen that Kolliker has formally renounced all adhesion to 
the free-cell-development theory, and has deliberately accepted Virchow' 's 
law of continuous development of cells only out of cells as an indisputable 
fact. And while theorists of variable character and calibre have been 
abusing Virchow as an innovator, and rejecting his facts on theoretical 



1861.] 



Kolliker, Human Microscopic Anatomy. 



209 



grounds, it is somewhat amusing to contrast with their ideas of the great 
Berlin pathologist, the sober opinion of a man like Kolliker. 

"The treatises of R. Virchow, who, of all living pathologists, has made the 
best observations, in his Archives and in the Wurzburg Proceedings, are of the 
greatest importance." (p. 6.) 

The support of an observer so careful and so independent as Kolliker will 
give great weight to the new views of cell-development ; and we may, per- 
haps, regard the doctrine of the spontaneous generation of cells as being as 
completely exploded as the doctrine of the spontaneous generation of ani- 
mals. 

And this one possibility of the evolution of form out of the formless, of 
the capability of organic fluids to assume bodily shape by their own energies, 
once denied authoritatively, how many curious pathological and physiological 
dogmas, not long ago quite dominant, are scattered forever to the winds. 
How utterly and completely that splendid exudation theory, which for 
twenty years has been dominant in the scholastic comprehension of morbid 
processes, falls to the ground, if the transuded fluid can in no manner serve 
as the blastema or form-producing liquid for new elements, if, in a word, 
the fluids be passive, and the organic forms the active agents in the or- 
ganic processes. How the old solidistic ideas, so long supposed to be quite 
trampled out of existence by the refined and systematic humoralism of E-o- 
kitansky and his followers, loom up once more with fresh force and vigour 
in a newer and more scientific dress ! 

It is not in our power to follow Kolliker through the six hundred pages 
of this elaborate volume. Much of the matter is identical with the details 
of the Sydenham edition, for many of these points are facts forever acquired 
for science ; but much also has been modified, the recent literature of the 
subject has been carefully considered, whole paragraphs have been remodelled 
or re-written, and the volume may be regarded as not merely an improvement 
upon former editions, but as wholly superseding them. To comment upon 
all the new points introduced would be to review the whole ground of his- 
tological progress during the past ten years, a task far too large for our 
present purpose. We shall, therefore, conclude with a few remarks on a 
subject which is important chiefly from its pathological relations. 

Within the last few years "connective tissue" has been made the object 
of a series of most interesting observations, and has constantly assumed 
fresh importance until the best modern investigators (Yirchow, Weber, &c.) 
have come to look to its elements for the origin of the great majority of 
"those pathological products (pus, lymph, cancer cells, &c), which were for- 
merly thought to spring up spontaneously in an organizable blastema. The 
true anatomy of connective tissue, and especially the process of its develop- 
ment is a subject related in the nearest manner to pathological doctrine. 
In his conceptions of connective tissue, as laid down in our present volume, 
Kolliker, while obliged to go a long way towards the abandonment of the 
older notions, as taught by Schwann, remains adherent to one of Schwann's 
notions, which careful observation shows so clearly to be incorrect that we 
must confess surprise at seeing it retained in this volume. He still asserts 
that the white fibrous element of connective tissue is developed by the elon- 
gation and subsequent fibrillization of the primitive embryonic cells, the 
nucleus of the cell remaining permanently imbedded in the bundle thus pro- 
duced. 

Pathological studies which accord fully in their results with Yirchow's 
No. LXXXIIL— July 1861. 14 



210 



Revieavs. 



[July 



doctrine of the histogenesis of connective tissue and the study of several 
human embryos from one inch long upwards, have so fully convinced us 
that this idea of the development of the white fibrous tissue so called is 
incorrect, that we cannot close without making a few remarks upon the 
subject ; for in fact white fibrous tissue wherever this exists represents not 
transformed cells, but the transformed matrix or intercellular substance, 
and this is true in the tendons and subcutaneous areolar tissue as well as 
in the so-called fibro-cartilages, where it has long been acknowledged. 

Kolliker, with great propriety, includes, under the " tissues of connective 
substance" (connective tissue group), not merely connective tissue properly 
so called, but also mucous tissue, yellow elastic tissue, cartilage, bones, and 
teeth. 

All these tissues possess, in common, certain structural and histogenetic 
points of the highest interest. 

They all originate as a mass of cells (primitive embryonic cells) nearly 
or quite in contact, between which as the developmental process proceeds a 
variable amount of fluid, semi-solid or solid intercellular substance, or ma- 
trix arises. 

The cells multiply in number by division, matrix being subsequently 
developed between the broods of cells in the same fashion as between the 
original or parent cells of the tissue. 

The cells may remain rounded or oval, increasing to a variable size, and 
presenting great diversities in contents (cartilage cells, adipose tissue cells), 
or they may become branched and stellate, the processes of the branched 
cells usually anastomosing so as to form intricate networks adequate to the 
transportation of fluids (connective tissue cells, cells of mucous tissue, pig- 
ment cells, bone cells, bone lacunas so-called). Or finally the cells may be 
transformed into long hollow fibres anastomosing with each other, and losing 
in their adult condition almost every trace of their cellular origin (yellow 
elastic fibres, dentinal tubules, and the like). 

In the actual condition of the adult tissues, these differences in the form 
of the cells are not of that sharply-defined kind, that every tissue of the 
group has its specific cells by which it is distinguished ; on the contrary, 
they pass into each other by the most gradual transitions, which is quite 
what should have been expected, when it is borne in mind that they all arise 
by the transformation of cells originally identical. 

The matrix or intercellular substance above alluded to as being developed 
between these cells pari passu with their development, is subject to as great 
a diversity in its transformations as the cells themselves ; besides the 
greatest diversities in quantity, the following chief qualitative transforma- 
tions may be noted between which every grade of transition exists. 

(1.) The matrix may remain semi-fluid, soft and jelly like, yielding a 
filamentous precipitate with acetic acid. This is "mucous tissue" so called, 
a term which Virchow applies to the vitreous humour of the eye, the umbili- 
cal cord of the new-born child, the cutaneous and subcutaneous tissues of 
the foetus, and many pathological formations identical in structure with 
these ; and although Kolliker limits this class within much narrower 
bounds, allowing the term mucous tissue to be applicable only to the vitre- 
ous humour, his description of the other tissues above mentioned accords so 
completely with the facts of the case, and his rejection of the term mucous 
tissue as applied to them depends so entirely upon his desire to classify 
tissues as they become in the adult state, rather than as they begin in the 
embryonic condition, that the precise limits of his classification is a matter 



1861.] 



Kolliker, Human Microscopic Anatomy. 



211 



which modifies in no essential degree the comprehension of the subject to 
be derived from his writings. 

(2.) The matrix may become solid, still retaining, however, a homo- 
geneous, more or less completely translucent character. This is especially 
the case in the cartilages (true or homogeneous cartilage, articular, costal 
cartilages, &c). The essential character of cartilage, however, is not to be 
found in this state of the matrix, for cartilages, at the beginning, are a mere 
mass of cells without any matrix; and this state, which is the normal initial 
condition of every cartilage, may remain permanent under certain circum- 
stances, as is normally the case, for example, in the cartilage of the external 
ear of the mouse and many other mammals. 

(3.) The matrix may become solid, and fibrillate as it solidifies, more 
rarely after it has become homogeneously solid. The fibrillated matrix 
constitutes the so-called white fibrous tissue. The fibrillization begins in 
the already existing fluid or jelly-like matrix in the immediate neighbour- 
hood of the cells, and proceeds from these outward into the matrix, and 
hence it happens while the process is yet incomplete, if the tissue be torn 
with needles, fragments of the fibrillated matrix are readily isolated, 
containing the cells imbedded, and the delicate cell wall being easily over- 
looked if appropriate treatment is not resorted to, the whole fragment has 
been regarded first by Schwann and his followers, and even yet by Kolli- 
ker, as a metamorphic condition of a cell, ivhereas in fact it represents 
a cell, plus a certain exterior and adhering fragment of the imperfectly 
formed matrix. 

The essential difference between such a mass of connective tissue as is 
found in a tendon or a ligament, and the areolar tissue so called, is to be 
found first in the mode of arrangement of the branched and anastomosing 
connective tissue cells, and secondly, in the fact that the whole or nearly 
the whole of the matrix solidifies in a fibrillated form in the tendon, while 
in the areolar form of tissue, only a certain limited amount of fibrillization 
takes place upon the cells and their branches, leaving more or less roomy 
spaces (areola?) between the anastomosing "bundles" thus produced. 

(4.) The matrix having solidified in either of the above methods may 
calcify from the deposit in it of lime salts, as in the well-known process 
of ossification. The cells then become the bone cells, which repose in 
spaces or lacuna? which in the dried and polished slices of the tissue con- 
stitute the well known bone lacuna?. 

Any of the tissues included in the above categories may undergo ossifica- 
tion, but the two tissues in which this is most frequent are the cartilages 
(development of bone from foetal cartilage) and connective tissue (develop- 
ment of bone from periosteum, and in exceptional cases ossification of 
tendons, &c). Even the mucous tissue may undergo ossification under 
favourable conditions (e. g., the rare but authentic ossifications of the 
vitreous humour). 

Such is a hasty survey of the modern conception of the connective tissue 
group, in which, with the exception of the development of the white fibrous 
matrix, Kolliker agrees perfectly with the more recent investigators. If now 
narrowing down our subject by the exclusion of bone, teeth, cartilage, and 
mucous tissue, we look for a moment exclusively at the typical tissue of 
the group connective tissue proper, we shall find that in the adult this tis- 
sue consists essentially of cells (connective tissue cells, connective tissue 
corpuscles of Yirchow, cells of connective substance, plasm cells and tubes 
of Kolliker). These cells are small, nucleated, generally branched, more 



212 Reviews. [July 

or less stellate, and anastomose by long processes, or tubes, so as to form a 
network ; between them a solid matrix, translucent, granular, or fibrillated, 
exists to a greater or less extent. These cells, which are readily demon- 
strated after colouring them by the imbibition of carmine (though they 
may be seen without reagents under favourable circumstances), are the 
essential anatomical element of connective tissue, just as bone cells are 
the essential anatomical element of bone. The transformation of some of 
these cells- into yellow elastic fibres, into pigment cells, or into adipose vesi- 
cles, the more or less complete fibrillization of the matrix, and its increase 
or diminution in quantity, its complete solidification or the formation in it 
of vacuoles of various sizes, these are circumstances which modify much 
the external aspect of the tissue in particular localities, and fit it to perform 
the special functions assigned to it in each ; but everywhere, no matter what 
transformations some of the cells have undergone, a certain number of them 
continue to present the characters above described, and thus retain the typi- 
cal anatomy of the tissue. And hence the anatomist, wherever he recog- 
nizes these elements, may affirm connective tissue to exist. Well-marked 
and beautifully anastomosing networks of such cells may be seen in thin 
sections of the brain and spinal cord, in the kidney, and in many other 
situations in which up to a very recent period the existence of connective 
tissue has been denied by respectable anatomists. Everywhere the connec- 
tive tissue cells serve at least a twofold purpose: on the one hand, they 
serve to convey the nutritive juices into the little territories of tissue, that 
lie within the meshes of the smallest capillaries that carry red blood — on 
the other hand, as they still retain the power of multiplying by division 
and producing broods of secondary cells under the influence of appro- 
priate irritations, they serve as the point of departure for the production 
of reparative material, and in virtue of the same set of nutritive laws act- 
ing under anomalous conditions may give birth to broods of cells, consti- 
tuting the several so-called pathological new formations. If with this 
origin of the majority of pathological tissues, we bear in mind the fact 
that even in the physiological condition the tissues of the connective tissue 
group are mutually convertible (e. g. the transformation of cartilage and 
connective tissue into bone, and of bone into connective tissue in the forma- 
tion of the marrow cavity of the long bones, &c), we shall readily under- 
stand why it is that the vast majority of pathological new formations are 
either evidently connective tissue, as in cicatrices, fibroid and fibro-plastic 
growths, fibrillated lymph, &c. &c, cellular elements rudimentary to the 
same, typically developed or variously deformed and aborted, as corpuscular 
lymph, pus, sarcomata, tubercle, cancer; or finally tissues of the connective 
tissue group'mio which ordinary connective tissue is physiologically conver- 
tible, as cartilage, adipose tissue, bone, &c. &c. 

We will dwell no longer on this subject, to which we have only alluded 
on account of its intimate connection with the modern doctrine of patholo- 
gical new formations. The production of new formations out of connec- 
tive tissue is not the whole sum and substance of pathological new forma- 
tions ; other tissues, especially the epithelia, may luxuriate into pathological 
growths, but yet connective tissue plays so large a role in the matter that 
it demands the most earnest attention. In conclusion, we commend the 
new volume of Kolliker to all our readers, as a safe guide to a knowledge 
of the minute anatomy of the tissues, and as presenting a closer approxi- 
mation to the actual state of histological information than is to be found 
elsewhere in the English or any other language. 

J. J. W. 



1861.] 



213 



BIBLIOGRAPHICAL NOTICES. 

Art. XIY. — Hand-look for the Military Surgeon : Being a Compendium of 
the Duties of the Medical Officer in the Field, the Sanitary Management of 
the Camp, the Preparation of Food, etc. ; with Forms for the Requisitions 
for Supplies, Rations, etc. ; the Diagnosis and Treatment of Camp Dysen- 
tery ; and all the Important Points in War Surgery : including Gunshot 
Wounds, Amputaiion, Wounds of the Chest, Abdomen, Arteries, and Head, 
and the Use of Chloroform. By Ohas. S. Tripler, M. D., Surgeon United 
States Army. And George C. Blackman, M. D. F. E. M. S., Prof, of Sur- 
gery in the Med. Coll. of Ohio, &c. &c. Cincinnati : Eobert Clarke & Co., 
1861. 12mo. pp. 163, including Appendix of Forms. 

A Manual of Military Surgery ; or Hints on the Emergencies of Field, Camp, 
and Hospital Practice. Illustrated ivith Wood Cuts. By S. D. Gross, 
M. D., Prof, of Surg, in the Jefferson Med. Coll. of Phila. Philadelphia: 
J. B. Lippincott & Co., 1861. 24mo. pp. 186. 

A Practical Treatise on Military Surgery. By Frank Hastings Hamilton, 
M. D., Late Surgeon 33d Reg. 4th Brigade 4th Div. N. Y. S. Artillery ; Prof, 
of Military Surgery, &c. &c. New York : Bailliere Brothers, 1861. 8vo. pp. 
234, including Appendix and Index, with several wood-cuts. 

The three small volumes, here announced in the order of their appearance 
from the press, will be regarded with unusual interest by the community at large ; 
and it is to be hoped that they may attract the favourable attention of the 
medical profession generally. Many of the topics are of universal interest at all 
times, and only more important in time of war because of the imperative nature of 
its demands and demonstrations. Every member of our profession, in fact, is 
always, and now especially, more or less involved in the performance of some of 
the duties and the application of many of the precepts which are discussed by 
the able and patriotic authors of these little works. 

These lessons in sanitary management and medical practice, no less than in 
dealing with the mischiefs of battle, are so essential to the saving of health and 
strength in ordinary life, that we hope to see an impression made upon the pub- 
lic mind in their behalf, and in support of medical authority, which nothing but 
the stimulus of present circumstances could bring about, and which may con- 
tinue to afford some compensation for the trial now upon us, long after the 
ordeal that aroused it has been safely passed. 

If there be any time when the value of true science and skill in medicine and 
surgery is properly acknowledged, it is in time of war. There can be no more 
uncompromising leveller of incompetence and charlatanism of every kind 
than the necessity of military service, where every step becomes a question of 
honour and dishonour, of life and death. So that in the medical corps, as 
in others, the really worthy officer may look forward in his career with a con- 
fidence that seldom falls to the lot of the practitioner in civil life ; and as with 
individuals, so, of course, with the profession in a body. Every one is now dis- 
posed to admit the weight of the obligation which rests upon our calling, and in 
some measure to appreciate the effort which medical men are making, to main- 
tain the vigour of the nation by doing what they can to protect and restore 
the health of its defenders, while they satisfy the cravings of humanity in ward- 
ing off disease and palliating the effects of violence. Let us not forget, then, 
that the crisis of the day, however painful in many aspects, has this among other 
consolations, that it presents an opportunity, to prove the power and the goqi 
will of the medical fraternity of our country, which is at least as unexampled 
and as pregnant with consequences as the convulsion which produces it. 



214 



Bibliographical 



Notices. 



[July 



Under this view of the occasion, the appearance and character of these almost 
impromptu publications are very significant in many respects. They are en- 
couraging as to the present spirit of our profession here, and full of promise 
in the future. Considering the short time allowed for the preparation of such 
text-books, and the many distracting influences at work throughout that interval, 
they are remarkably well adapted to their purpose, each in its peculiar way, and 
exhibit evidence of an ability to convey the required instruction, and of an alert- 
ness in imparting it, which is equally gratifying to our national and professional 
pride. Whatever may be the course and the event of the unhappy political 
contest, that share of the struggle to which these hurried offerings are addressed 
is, under the auspices of such beginnings, sure to end in permanent good. 

We shall not pretend, in a brief notice of these works, to dwell upon the points 
of practice discussed in them ■ although some of the chapters are so interesting 
and important, especially in the " Hand-book" of Drs. Tripler and Blackman, 
that we hope to be able to consider them more at length on another occasion. 
For the present a very cursory glance at the leading characteristics of each 
volume will answer the purpose of inviting especial attention to them as indis- 
pensable monitors to the recently appointed surgeons and assistant surgeons, 
and as useful companions even to those of higher grade. 

The first of the three is so fully described in its title that we may refer to this 
for the list of contents and for an idea of their nature. Of the ten chapters, the 
first six were the substance of the lectures on military surgery which Dr. Tripler 
had delivered for three years past in the Medical College of Ohio, at the invita- 
tion of Dr. Blackman. Three of these chapters had to be arranged by Dr. 
Blackman from unfinished notes left with him by Dr. T., who was summoned to 
headquarters before his revision of his labours was completed. Of the last four 
chapters, the sixth, seventh, and eighth, On Wounds of the Abdomen, Head, 
and Arteries, respectively, were compiled by Dr. Blackman, and one, the tenth, 
On the Use of Chloroform, was taken from the "Notes" of Mr. Macleod on 
the Surgery of the Crimean War. 

In his first chapter, Dr. Tripler instructs the military medical officer in his 
routine duties in camp and field, as to the organization of field hospitals, modes 
of procuring supplies, and similar matters, in such a manner as to save him a 
great deal of time and trouble in acquiring an experience for which no previous 
knowledge could be an adequate substitute. Chapter II. is equally practical in 
its hints on military hygiene, including the inspection of recruits, the regulation 
of the diet and cooking, with tested recipes for food and drink, and the general 
management in camp and on the march. These two chapters are peculiarly 
valuable on account of the veteran practical experience on which they are 
evidently based. They are so clear and complete in themselves as to establish 
the high claims of the book without reference to the remaining chapters. Our 
only regret in relation to them is that the author had not the time to amplify 
and illustrate a little more in regard to sanitary matters and hospitals ; and that 
he did not quote his own excellent instructions, already published under author- 
ity of the War Department, for the examination of recruits, instead of modestly 
referring to them only, along with those of Henderson. The duty of selection 
is so important, and has been hitherto so much neglected in mustering the 
volunteers, that definite regulations are absolutely indispensable, and might be 
introduced without materially increasing the bulk of a volume which is so por- 
table as to be easily within the compass of the surgeon's pocket. 

The next four chapters, on camp dysentery, gunshot wounds, amputations, 
and wounds of the chest, are admirable on each of these several topics. We 
have read them carefully through, and some portions of them repeatedly, with 
the greatest interest. They contain the best practical and theoretical view 
and condensed exposition of the various important questions involved, that we 
have met with in the same space in our language, and embody the results of a 
large amount of experience and a discriminating, candid, and able study of 
the most approved authorities, old as well as recent. We greatly like his 
views of the pathology and treatment of camp diarrhoea and dysentery, and 
would have been glad to find other diseases incident to military life noticed to 
some extent in the same practical manner. The bowel complaints of the soldier 



1861.] Triples,, Gross, Hamilton, Military Surgery. 215 



appear to resemble closely, in character, etiology, and susceptibility to certain 
modes of cure, those of the inmates of prisons and asylums, a considerable ex- 
perience with which has long since convinced us of the propriety of his thera- 
peutic management, especially in the resort to saline purgatives in the beginning 
of attacks of dysentery. He mentions the happy effect in chronic diarrhoea of 
small doses of Fowler's solution, and, in other cases, of the syrup of the per- 
chloride of iron. He says nothing of the use of creasote in these attacks, a 
remedy which is of great value in certain forms of diarrhoea, as well as in cholera 
morbus, cholerine, and cholera. We cannot dwell upon the surgical topics dis- 
cussed by Dr. Tripler, and must content ourselves with again remarking that 
these four chapters embody the most practically effective summaries of the 
kind that we know of in any work upon the subject. 

Dr. Blackman has presented an excellent digest of the best authorities on 
wounds of the abdomen, head, and arteries, in which all that is essential is un- 
usually well condensed, so as to constitute a very useful and worthy accompani- 
ment to the labours of his associate. The chapter from McLeod on chloroform 
is valuable of course, but an exhibition of the American experience in the use 
of ether as well as of chloroform, including the views of Porter and others in 
Mexico and since, would have been much more satisfactory. It is especially in 
the use of anaesthetics in military surgery that we hope to gain more experience 
and perhaps make some approach to positive knowledge, in the observations of 
the future campaigns in this country. The appreciation of articular resections, 
and different modes of amputation, the treatment of gunshot fractures, and 
management of operations with regard to shock ; the use of metallic and needle 
sutures, and the resort to acupressure ; the employment of hyponarthecy or 
suspending apparatus, and the more efficient resort to extension and counter- 
extension in compound fractures; certain questions as to the treatment of 
arterial hemorrhage, and as to modes and materials of dressings, are some of 
the subjects of inquiry which we hope to see tested in the crucible of American 
experiment; but none of these is more important or more in need of elucidation 
than the determination of the respective merits and demerits and proper use of 
ether and chloroform as anaesthetic agents in field and hospital surgery. 

The Handbook is furnished with an appendix of forty-two pages, consisting 
of the supply tables, forms for requisitions, accounts, returns, registers, pre- 
scription and diet book, muster-rolls, reports, and other similar documents, in 
which the mode and means of conducting the official business of the service are 
furnished in such a manner as to be within the comprehension . and reach of 
every beginner. This must prove a valuable feature of the work to the 
volunteer surgeon. Being a thin duodecimo, the volume is very easily carried 
about the person ; and with a light flexible cover, would be well worth keep- 
ing always at hand, as the best available guide for constant reference. The only 
fault we have to find is with the paper and printing, the former not being what 
it ought to be, and the latter being in too small a type. The probable early 
call for a new edition, however, will enable the publishers to remove these ble- 
mishes. With such an admirable basis it is to be hoped that the authors will 
have the time to extend the work itself, so as to contain their latest experience: 
and, at all events, to render their volume as complete a systematic instructor 
on all legitimate subjects as it is now a competent adviser on those which are 
most essential. 

The manual of Dr. Gross is a neat little 24mo., well printed on good paper, 
and arranged in thirteen chapters, which contain a great variety of "hints on 
the emergencies of field, camp, and hospital practice." It is not easy to describe 
this work so as to give a clear idea of its scope and calibre ; and we prefer taking 
the author's own account of it before going further. Its publication was the 
result of "an ardent desire to be useful to the young physicians who have so 
hurriedly entered the volunteer service, perhaps not always with a full know- 
ledge of the weighty responsibilities of their position. It treats, very succinctly, 
of various matters not generally discussed, except in large and ponderous vol- 
umes, inaccessible in the camp and on the battle-field. It is essentially a book 
for emergencies; portable, easy of reference, always at hand." 

The object of the indefatigable author will doubtless be fully realized in the 



216 



Bibliographical Notices. 



[July 



usefulness of this smallest of his books, in the hands of many other young phy- 
sicians besides those to whom it is expressly tendered, since it contains a large 
amount of practical information that must prove no less advantageous to the 
inexperienced practitioner in civil life than to the army tyro. Some of the 
hints, especially as to the materia medica and dietetics, struck us, in fact, as 
much better adapted to ordinary private practice than to that of the field 
and camp. Small as it is, Dr. Gross' volume includes a much wider range of 
topics than that of the Cincinnati authors ; and hence, although necessarily very 
brief in its mode of treating many matters, and by no means uniform in dealing 
with those of equal practical importance, its great amount of information and 
numerous practical suggestions render it a valuable adjuvant to the larger 
manual. To at least some of our volunteer medical officers, therefore, we appre- 
hend it must be deemed an essential one, and would recommend it strongly for 
that purpose, even to those who may not suspect their need of such assistance. 

In regard to dressings, we are glad to find that Dr. Gross recommends the 
silver suture ; not because we believe in any virtue of the silver, having become 
convinced by hundreds of trials that lead and iron are fully equal to the more 
expensive metal for the union of external wounds, but because the metallic 
suture will, or ought to, play a very important part hereafter in. the dressing 
of wounds received in action. Spools of fine well-annealed iron and lead wire, 
and, if insisted on, silver wire, are as easily obtained and carried as silk, and 
may enable the surgeon and his patients to dispense with a large amount of 
adhesive plaster, vastly to the advantage of both parties, especially in tropical 
districts and seasons. Collodion has its use in some cases, and isinglass plaster 
is a very desirable succedaneum in a much larger number, particularly in warm 
weather; but the metallic suture, separate or continued, maybe, and is often 
substituted with great success for all other means of union. The insect pin, 
with its twisted suture of thread or wire, is sometimes, and justly, preferred as 
a material improvement upon the separate metallic suture. It possesses advan- 
tages, when of the proper fineness and skilfully employed, which especially adapt 
it to campaigning surgery. It is to be regretted that, among the notes on hospital 
materials, nothing is saicl of the most convenient forms of the immovable appara- 
tus in the dressing of fractures. The different combinations of calcined plaster 
with gum Arabic, starch, or dextrine, or with flour, may be easily provided, and 
would certainly prove invaluable in many cases. The same may be said of Dr. 
N. R. Smith's outline wire anterior splint, the various modifications of which 
are admirably adapted to the emergencies of military and naval surgery, as 
indeed to those of ordinary practice. "With a coil of thick iron wire, or even 
with a lot of common iron hoops, an ingenious or well-trained dresser may 
furnish a supply of splints for upper and lower extremities, which would meet 
the exigencies of the service much better than the cumbrous and costly con- 
trivances which are too apt to be employed. 

Dr. Gross refers to a larger number of disorders than are noticed in the other 
volumes, but, like his competitors, he says nothing about heat-exhaustion and 
sunstroke, a source of casualty well known to the French and British armies, 
and already threatening to be a common one in ours, but not understood as it 
ought to be by inexperienced officers. 

A brief enumeration of the subjects of the different chapters of the volume 
will give an idea of the variety of its material. The first two chapters are intro- 
ductory, containing, among some twenty pages of general remarks, a list of lead- 
ing works on military surgery. Then follow short chapters on the Qualifications 
and Duties of Military Surgeons ; Medical Equipments ; Stores and Hospitals ; 
"Wounds and other Injuries; Amputations and Resections — including some valu- 
able statistics; 111 Consequences of Wounds and Operations; Injuries of the 
Head. Chest, and Abdomen: Diseases incident to Troops; Military Hygiene; 
Disqualifying Diseases; Feigned Diseases; Medical, Surgical, and Dietetic For- 
mulae; and, finally, an appendix containing a copy of regulations for the admis- 
sion of physicians into the medical staff of the army, also a statement of the 
pay and emoluments of surgeons and assistant surgeons. 

The work of Dr. Hamilton is on a larger scale, and is more of a library book 
than either of the others, being' offered as a "Practical Treatise." It is evi- 
dently more elaborate in character, and as a systematic treatise by a professed 



1861.] Tripler, Gross, Hamilton, Military Surgery. 217 



lecturer upon the subject, lias bad the benefit of a somewhat longer period of 
incubation. It is more methodically arranged, and, on some topics, much more 
full, at the same time that questions of interest are considered which are un- 
touched in either of the manuals. The young medical officer would do well, 
therefore, to provide himself with a copy of the treatise to accompany the other 
two. By cutting down the unnecessarily wide margins, and securing a flexible 
cover, with pocket and tucks, if desirable, he will obtain a very convenient as 
well as neat and useful remembrancer for the camp and post, if not the field. 

There are fourteen chapters, a short appendix, and an index ; the last four 
chapters being on Anaesthetics, and on Hospital Gangrene, by the author ; on 
Dysentery, by Prof. A. Flint; and on Scurvy, by Prof. B. W. McCready. 

Chapter I. is devoted, in twenty-seven pages of introductory matter, to vari- 
ous questions of general interest in regard to the nature, importance, and re- 
quirements of the study and the service to be discussed. The second chapter 
is a complete and very useful one on Examination of Eecruits, which contains 
all that is needed on this important duty, including all that is essential from the 
authorized manual prepared by Dr. Tripler. 

The remaining eight chapters treat respectively of General Hygiene of Troops ; 
Bivouac, Accommodation of Troops in Tents, Barracks, Billets, Huts, &c. ; Hos- 
pitals ; Preparations for the Field ; Hygienic Management of Troops upon the 
March ; Conveyance of Sick and Wounded Soldiers ; Gunshot Wounds : Ampu- 
tation. Some of these chapters have the advantage of well executed illustra- 
tions, and are interesting, and, to some extent, novel ; but we cannot help feeling 
a degree of disappointment at the meagreness of all of them, except, perhaps, 
the one on the examination of recruits ; and even in that we should be glad to 
see some practical illustration of the injurious working of insufficient inspec- 
tions, such as the records of the Mexican campaigns would certainly afford. 
We regret also to notice the omission of such topics as wounds of the chest, of the 
head and face, of the abdomen, of the bloodvessels, dressings and operations on 
the field, special management of fractures (splinter and gunshot) on the field 
and temporary post, and on the march ; not to mention others which may 
occur to the reader perhaps when he most needs the absent information. Some 
of these topics are touched upon in the chapter on gunshot wounds, but not 
sufficiently. Others may not be regarded by the author as admissible under his 
rule excluding those points which are usually " considered in general treatises." 
As the work will be wanted to take the place, as far as practicable, of the general 
treatises, however, and as those topics are usually considered at length in works 
on military surgery, their absence will be very apt to be felt as a defect by 
those who may look to the work as a standard one. These shortcomings are 
doubtless the almost inevitable result of the necessary haste with which the 
volume was finally arranged and carried through the printer's hands ; and we 
have no idea of finding fault with it, except as to its completeness as a "practical 
treatise," even upon the points alone intended to be taught. Well arranged, well 
written, interesting, instructive, and handsome, it certainly is ; a more attractive 
and complete work than either of its competitors, also ; and yet neither compre- 
hensive nor full enough to enable us to do without the admirable practical expo- 
sitions of the handbook, or the numerous hints on minor medicine and surgery 
of the manual. A thorough work upon the principles and practice of military 
surgery, such as is really wanted, or even an exclusively practical treatise on so 
extensive a subject, could hardly be condensed within the compass of two hundred 
and thirty pages, especially in the unprecedentedly short time that must have 
been allotted to the labour. The author is fully conscious of the difficulty, as is 
evinced by the apprehension which he expresses in his preface. That it will be 
amply done away with in a future edition prepared under more favourable cir- 
cumstances, no one who knows anything of the ability, learning, and untiring 
industry of Dr. Hamilton can entertain a reasonable doubt. 

In conclusion, we would earnestly advise every surgical aspirant, and every 
student of our profession, to provide himself with a copy of each of these 
volumes, as valuable assistants for which there are no available substitutes, 
and as curious way-marks of the progress of medical teaching in this country, 
as well as significant mementoes of a momentous passage in that countrr s his- 
tory. E. EL. 



218 



Bibliographical Notices. 



[July 



Art. XT. — Another Letter to a Young Physician : to which are appended 
some other Medical Papers. By James Jackson, M.D., &c. 12mo., Boston, 
1861. 

We have had great pleasure in reading this sequel to a volume which we no- 
ticed several years ago. 1 Indeed, upon all subjects within their competency; the 
judgments of men so sober-minded, impartial, kind-hearted, and accomplished as 
Dr. Jackson, are fitted to inspire respect and confidence. No one in the medical 
profession enjoys a higher reputation for sound reason and probity; and as he 
has now arrived at that ripe age when passion and prejudice have but little 
power to warp the judgment, whatever he may say upon a subject of interest is 
sure to command attention. 

In the preface it is stated that " a grave question has been agitated" among 
the good people of Massachusetts by the delivery of Dr. 0. W. Holmes' lecture 
on "Currents and Counter-Currents in Medical Science," and "the question is 
whether there is any good to be derived from the practice of medicine." Our 
readers will remember that the lecture in question was reviewed in this Journal, 2 
and that throughout the profession a general feeling of regret was experienced 
that one so gifted as Dr. Holmes, and occupying so respectable an official posi- 
tion as he, should make use of language which the greater number felt to be a 
satire if not a libel upon the practice of medicine. The smaller number, and the 
better informed, remembered, however, that the author was an orator and a 
poet, and had had but little opportunity of acquiring that personal knowledge 
of practical medicine which would have lent authority to his judgment. It was 
only natural, they thought, that he should follow his most habitual bias, and for 
the sake of startling antitheses, quaint and novel metaphors, and pungent epi- 
grams, should yield to the temptation of flouting the venerable art and science 
whose mysteries he professes to expound. Poets claim and receive a license 
not accorded to other men. They must speak as the spirit moves them ; and if 
occasionally they utter vaticinations which, on the sober lips of science would 
be raving, they should be listened to with composure, and not answered in the 
same high-pitched key in which their tirade has been delivered. The soothing 
system is appropriate in this as in other cases marked by " the eye in a fine 
phrenzy rolling." 

Some such idea, we fancy, was in the mind of Dr. Jackson when he resolved 
to compose this letter ; for, starting from a seeming acquiescence in the spirit 
of the lecture, and suggesting that Dr. Holmes was misunderstood by those who 
regarded him as denying the utility of our art, he proceeds to state the question 
"whether the sick are more helped or hurt" by medicinal drugs ? and then, after 
reminding us that some very eminent and very experienced physicians have been 
sceptical on the subject, he glides into a notice of the abuses in the employment 
of drugs and a eulogy of the sanative powers of Nature. Having paid this tri- 
bute to courtesy and kindness, he exposes the fallacy of reasoning and the more 
than extravagance of statement in Dr. Holmes' lecture, and concludes that its 
arguing for the disuse on account of the abuse of medicines is neither logical 
nor wise. Indeed, he is convinced that his friend, Dr. Holmes, is of the same 
opinion ; but, as if to leave him no pretext for not being so, he proceeds to enume- 
rate some of the more striking illustrations of the value of drugs in the treatment 
of disease. Of mercury, antimony, arsenic, cinchona, and opium, he has much 
to say that corroborates the settled judgment of the profession concerning their 
virtues, and as to the last he assures us that without it he would hardly be willing 
to practice medicine. Nor does he recommend these medicines in trifling doses. 
On the contrary, he recognizes circumstances which justify the prescription of 
mercurial preparations until the mouth is made sore ; the emetic use of anti- 
mony at the commencement of typhoid fever is a method almost peculiar to 
himself, and one for which he claims very great value ; he also advocates it in 



1 Jan. 1856, p. 136. 



2 Oct. 1860, p. 462. 



1861.] 



Jackson, Another Letter to a Young Physician. 



219 



the forming stage of nearly all inflammations ; ipecacuanha and squill he hardly 
subordinates to this potent remedy in appropriate cases, and adds that other 
medicines might be mentioned more or less similar to antimony, &c. Along with 
opium he classes conium, hyoscyamus, aconite, and the anaesthetics as having 
each its appropriate sphere of usefulness, and as to quinia, he is hardly behind 
the boldest of those who use it in heroic doses. As arsenic, he remarks, " has a 
bad character with many, I feel bound to testify that it is as mild and gentle in 
its effects on the human body as almost any efficient medicine ever employed by 
us." Iron he would not dispense with, nor bismuth, cascarilla, quassia, or cod- 
liver oil. Of cathartics, he remarks : " It would seem that we could hardly live 
without the use of cathartics — they are necessary ;" and of depletion he is not 
afraid to make the unfashionable remark, that "the use of the lancet should not 
be altogether abandoned." On the contrary, he prescribes it in the thoracic 
inflammations even of young children, and in the forming stage of acute diseases 
generally. In acute rheumatism, indeed, he does not recommend it, but employs 
a still more active and perturbative agent, colchicum. requiring it to be repeated 
every four or six hours, until it brings on copious discharges. Guaiacum he lauds 
in the subacute form of this disease. "There are many more medicinal drugs, 
too good to be expunged from the list of the materia medica, which," says Dr. 
J., " I might mention. Among the more powerful of these are elaterium, digitalis, 
diluted hydrocyanic acid, and iodine ;" and, among the milder drugs, " spirit of 
nitric ether, the compound spirit of ether, the solution of acetate of ammonia, 
valerian, and assafcetida, old friends, whom I would not like to part with. The 
same may be said of mustard, the water of ammonia, croton oil, chloroform, and 
cantharides, for external use." 

And this is a specimen of the materia medica of a physician who appears as 
the ally and champion of the witty orator who, after securing opium, " a few 
specifics which our art did not discover, and it is hardly needed to apply," (!) 
with wine and anaesthesia, would have us throw into the sea all the rest " of the 
materia medica as now used," if he were not restrained by a charitable regard for 
the health of the fishes ! Well might Dr. Holmes exclaim " non tali auxilio nec 
defensoribus istis /" But well may we rejoice that in his own calm yet authori- 
tative way, Dr. Jackson should have furnished so perfect an antidote to the 
inconsiderate and incorrect estimate placed by his colleague upon medicine. 
Even more we must be gratified to find so able an advocate of the energetic 
treatment of disease at a time when , many among us allow themselves to be 
ruled by the popular prejudice which an absurd medical heresy has engendered, 
and are tempted to withhold the active remedies, whose virtues were demon- 
strated centuries before globulism was invented, and barren scepticism, or mere 
faineantise, was dignified with the name of scientific expectation. 

An appendix to the principal essay in this volume contains several inte- 
resting articles in the form of notes. The first is an account of an attack of 
cholera infantum, which the distinguished founder of the Lowell Institute suffered 
in his infancy, and which would certainly have nipped in its bud the life of this 
child of promise, had not Dr. Jackson, having no fear of sceptical doctors or 
opinionated laymen before his eyes, treated the case with small doses of calomel 
and castor oil, like a sensible and orthodox physician. Indeed, we are not quite 
sure that this treatment, which is now so generally approved, did not originate 
with him. Dr. Clark, of Dublin, and Dr. Cheyne, of Leith, however, used it about 
the same time. The case of Mr. Prescott, the historian, forms the subject of 
another note. It is full of interest. Its special relation to the principal topic 
of the work consists in the fact that for the relief of a violent inflammation of 
the eye, which turned out to be rheumatic, more than seven pounds of blood 
were drawn in the course of five days, besides which the patient " was purged 
abundantly, was blistered freely, was kept in the dark, and on the lowest diet ; 
also the vessels of the conjunctiva were divided twice." If Dr. Jackson had 
been a pupil and imitator of Dr. Rush, whom he is disposed to blame for his 
heroic system of therapeutics, he could not more strikingly have illustrated his 
own faith in the efficacy of vigorous and prompt treatment on a proper occa- 
sion. 

In the concluding paper, Dr. Jackson presents a critical history of the disease 
• ■ 



220 



Bibliographical Notices. 



[July 



of which Washington died. He defends the treatment employed by the great 
man's physicians, which consisted of bloodletting, calomel and antimony, 
and warmly reprehends the opinion that inaction would have been warranted by 
an ignorance of the real nature of the attack. His opinion of its precise cha- 
racter Dr. Jackson does not expressly declare, but contents himself with naming 
it acute laryngitis. He. however, describes the ©edematous as one of its ana- 
tomical forms, and as that which probably terminated Washington's life. In 
all probability such an attack occurring in so robust a patient as was this illus- 
trious man, would at the present day be cured by the operation of tracheotomy, 
a remedial measure which, as well as many other heroic modes of treatment, is 
not likely to be abandoned because cobweb-brained theorists abjure common 
sense, and witty poets make merry at the expense of the sober realities of 
medical practice. A. S. 



Art. XYI. — Reports of American Institutions for the Insane. 

1. Of the State Hospital of Pennsylvania, for the year 1860. 

2. Of the Western Pennsylvania Hospital, for the year 1860. 

3. Of the Mt. Hope Institution, for the year 1860. 

4. Of the Eastern Kentucky Asylum, for the fiscal year 1859-60. 

5. Of the Central Ohio Asylum, for the fiscal year 1859-60. 

6. Of the Southern Ohio Asylum, for the fiscal year 1859-60. 

7. Of the Indiana Hospital, for the fiscal year 1859-60. 

8. Of the Illinois State Hospital, for the fiscal years 1858-59 and 1859-60. 

1. Comixg once more to our accustomed review of the reports annually issued 
from the American Institutions for the Insane, the first w T hich we find upon the 
list is that of the State Lunatic Hospital of Pennsylvania. It contains the 
numerical results of the medical history of the year just closed; and we copy 
from them such as are of the greatest importance. 

Men. Women. Total. 



Patients in hospital, December 31, 1859 . . 149 125 274 

Admitted in course of the year .... 73 71 144 

Whole number 222 196 418 

Discharged, including deaths .... 69 58 127 

Eemaining, December 31, 1860 . . . .153 138 291 

Of those discharged, there were cured 14 17 31 

Died 6 2 8 

Admitted, from opening of hospital . . . 777 559 1336 

Discharged, cured 136 100 236 

Died 112 66 178 



Died, in 1860, from exhaustion of chronic mania, 4; exhaustion of acute 
mania, 2 ; suicide, 2. In neither of the cases of suicide was any suspicion enter- 
tained of a propensity to self-destruction. 

Exhibitions of pictures with the magic lantern, and lectures upon various 
subjects have been continued, as for several preceding years, as entertaining, 
instructive, and curative means. 

" The great want," says Dr. Curwen, "which is more and more sensibly felt, is 
more general variety of occupation and agreeable diversion during the period 
from October to April, which shall place in the reach of the officers the means of 
giving to each inmate regular, systematic bodily exercise, and at the same time 
call into play the energies of the mind, and give such employment to its powers 
as may tend to drive off morbid fancies and aid in the re-establishment of healthy 
action. 

" The bowling saloon, for the erection of which Miss Dix, ever forward in 
every good work, placed in my hands three hundred dollars, from the Philadel- 
phia fund, has been completed, and I have no doubt will be the means of health- 
ful exercise and agreeable recreation to a very large portion of our household, 



1861.] 



American Insane Hospital Reports. 



221 



present and prospective. The building has been arranged so as to be as light 
and cheerful as it could be made, and, with two alleys, ample means are offered 
for as much physical exercise as may be proper and healthful." 

Several pages of the report are occupied by an exposition of " a few principles 
which may lay the foundation for a more distinct understanding of what may be 
said on the prevention of insanity." We commend these observations to the 
attention of the profession, and, would our space permit, we should be pleased 
to quote them in full. 

2. The report for 1860 of the Western Pennsylvania Hospital affords gratify- 
ing evidences of the present flourishing condition of that institution, as well as 
the pledges of its prospective growth. The report is embellished not only with 
a picture of the building now occupied, but also with a beautiful perspective 
view and a ground-plan of the far more extensive one which has been com- 
menced, for the accommodation of the insane patients of the hospital, a few 
miles from the city of Pittsburg. The central edifice of this establishment, 
and a wing upon either side, the whole presenting a front of about 270 feet, are 
already " under roof." Another purchase of land has been made, so that the 
Hospital farm now consists of about 280 acres. All the measures thus far taken 
indicate an intention on the part of the persons who have charge of the institu- 
tion, to make it, at no very distant day, a fit peer for the best of its kind in the 
country. This new establishment has been named the " Dixmont Hospital for 
the Insane," as a grateful token of the sense entertained by the Board of Man- 
agers for the philanthropic labours of Miss Dorothy L. Dix. 

Men. Women. Total. 

Patients in the hospital, January 1, 1860 . 
Admitted in course of the year . 

Whole number 

Discharged, including deaths 
Remaining, January 1, 1861 
Of those discharged, there were cured 

Died 

Admitted since opening, April 1, 1856 

Discharged, cured 

Died 

Died, in 1860, of apoplexy, 2; of consumption, 2; exhaustion of acute mania. 
2; chronic diarrhoea, 1; cancer of stomach, 1; general paralysis, 1; dropsy. 1. 

" For the amusement as well as the occupation of our patients, we have 
availed ourselves of every means within our reach —such as reading, games, and 
concerts ; but we are satisfied that they are entirely too limited. The money 
invested in the erection of a bowling alley, the purchase of a magic lantern, and 
other sources of amusement, would prove a judicious investment, giving its 
return in an increased per centage of cures, as well as affording a pleasant pas- 
time to the secluded members of our household." 

It is greatly to be regretted that, after all the exertions for the amelioration 
of the condition of the insane during the last thirty years, no b'etter statement 
than the following can be made of the condition of things in a State which has 
been one of the most active in the benevolent enterprise alluded to. Will not 
Pennsylvania redeem her character in this respect ? 

" We fear the condition of the insane poor throughout the State is but little 
understood, and that the impression produced by the memorial to the Legisla- 
ture by Miss Dix, the indefatigable friend of the insane, revealing the wretched- 
ness and suffering endured by this class of citizens, a few years since, and result- 
ing in the erection of hospitals for their care, has not been permanent in the 
deeper recesses of jails and poor-houses, and that the same sad condition of 
things exists as before. 

" The many statements that are made to us of cruelties which the insane are 
compelled to bear, at the hands of their friends and relatives, of one confined 
in a strong wooden cage, of another chained in a dark room, of another severely 
whipped as a method of cure, lead us to believe that the instances of cruelties 



61 


39 


100 


56 


53 


109 


117 


92 


209 


58 


40 


98 


59 


52 


111 


29 


17 


46 


5 


5 


10 


265 


176 


441 


107 


58 


165 


31 


12 


43 



222 Bibliographical Notices. [July 

and neglect at the hands of unpaid and reluctant keepers, are not few, particu- 
larly when we have witnessed recently in a receptacle for the insane, five men 
chained to the floor, manacled and entirely destitute of clothing, with no beds 
but bags of straw, and no light but that which struggled into their gloomy 
abodes through the iron gratings in the doors, their cells filthy in the extreme, 
and the atmosphere unfit to breathe. In adjoining rooms we found the quiet 
harmless female, the raving maniac, who made night hideous with his yells and 
clanking chains, and the simple idiot child — and all under the care of an imbecile 
keeper. 

" When we see patients brought to the hospital securely tied with ropes, or 
heavily ironed, and bearing upon their persons marks of violence, and know that 
others, who, while here, enjoyed entire freedom from personal restraint, have 
been removed through motives of economy, and are manacled and chained to 
the floor of their cells, we cannot but hope that the day will soon come when a 
more enlightened public sentiment will be directed to these evils and apply the 
proper remedy." 

3. From the report for 1860 of the Mi. Hope Institution, we learn that a part 
of one wing of the Mt. Hope Retreat, the new establishment of the institution 
in question, has been completed and is already occupied by patients. The two 
will continue to be occupied until the latter shall have been completed. 

Men. Women. Total. 

Insane patients at beginning of the year 
Admitted in the course of the year 

Whole number 

Discharged, including deaths 
Eemaining at the end of the year 
Of those discharged, there were cured 
Died . . . . ..... 



71 


106 


177 


71 


64 


135 


142 


170 


312 


70 


55 


125 


72 


115 


187 


30 


23 


53 


11 


5 


16 



Causes of death. — General paralysis, 5; phthisis pulmonalis, 2; acute mania, 
3; exhaustive mania, or febrile delirium, 3; organic disease of heart, and dropsy, 
1 ; rupture of aneurism of the aorta, 1 ; gastric ulcer, with hsematemesis, 1. 

The system of moral treatment at this institution embraces "musical parties," 
" social reunions," and "reading parties." " On Christmas day, about one hun- 
dred female patients partook of their usual entertainment in the large parlour, 
which was fitted up with evergreens appropriate to the occasion." The 4th of 
July was observed by festive parties in the groves belonging to the institution. 

It would appear, from the subjoined extract, taken from the remarks upon the 
different forms of disease among the patients of the last year, that the theories 
of other men, most of them persons of little or no experience in mental dis- 
orders, have not, in the mind of Dr. Stokes, overcome the effects of observation 
in regard to one alleged form of disease. 

" To the variety of mental derangement styled moral insanity, eight cases 
belong. In the individuals comprehended in this class, we have presented those 
unfortunate specimens of humanity whose characters having grown and been 
modelled after a certain abnormal type, the impossibility of a reformation, in all 
its utter hopelessness, has become apparent. No amount of discipline, no efforts 
to mould again the disposition, propensities, and passions now avail; and, be- 
cause they render themselves insupportable in their families, and are turbulent 
in their conduct, and erratic in their habits, they are necessarily banished from 
society and shorn of their civil and political rights." 

Another class of cases are thus noticed: — 

" Suicidal propensity was exhibited in twelve cases. This form of insanity is 
much less frequently observed among persons carrying on occupations out of 
doors, than among artisans who pursue their employment within doors, and take 
little muscular exercise. Statistics fully show that suicide is not so often com- 
mitted by masons, carpenters, and butchers, as by tailors, shoemakers, and 
bakers. A similar result is obtained by comparing the suicides in the class of 
labourers with those among artisans and tradespeople ; for the tendency to sui- 
cide is more than twice as great among artisans as it is among labourers. The 



l 



1861.] 



American Insane Hospital Reports. 



223 



disadvantages under which the sedentary artisan labours in this respect may be 
greatly mitigated. The workshops of all artisans admit of immense improve- 
ments in ventilation. Opportunities and facilities for out of door exercise should 
be afforded. Public walks and parks would afford the artisan an opportunity 
of refreshing his exhausted limbs, and respiring the fresh air ; and the health 
and temper of the sedentary workman would be much ameliorated by affording 
facilities in towns for athletic exercises and simple games out of doors, which, 
while they bring the muscles into play, unbend, excite, and exhilarate the mind." 

4. We are happy to chronicle the fact, that in the course of the past year, 
" one hundred and thirty acres of excellent land" have been added to the here- 
tofore limited domain of the Eastern Kentucky Lunatic Asylum. "We now 
have ample means," says Dr. Chipley, " of giving healthful employment to those 
whose previous habits make labour a necessity ; and sufficient extent of grounds 
to afford agreeable exercise and recreation to all the inmates of the Asylum, 
without the necessity of resorting, as heretofore, to the highways and grounds 
of the adjacent country." * * * * "I am more than ever convinced." he 
continues, "that well regulated moderate labour is one of the most efficient 
agents in the restoration of the curable, and that it is absolutely essential to the 
comfort and happiness of a large portion of those who are doomed to pass their 
whole lives without the rational world. I have men daily employed in agricul- 
tural and other pursuits who would be rendered furious and intractable by a 
single week's close confinement. I consider the profit derived from lunatic 
labour as of secondary importance ; it is proper to make them self-supporting, 
as far as may be consistent with their interest ; but the great object of restora- 
tion, where this is possible, should never be lost sight of; and, failing in this, 
humanity demands such measures as are calculated to afford bodily health and 
all the comfort and happiness the insane are capable of enjoying. This twofold 
object is kept steadily in view in all the labour assigned to the inmates of this 
institution ; and if any pecuniary profit results, it is hailed only as an incidental 
advantage. During my administration of six years no one has ever inflicted 
any injury on his fellows, either in the field or shops." 



Men. Women. Total. 

Patients in the asylum, October 1, 1859 .- .130 98 228 

Admitted in course of the year .... 33 17 50 

Whole number m . .163 115 278 

Discharged, including deaths .... 29 17 46 

Eemaining, October 1, 1860 .... 134 98 232 

Of those discharged, there were cured 14 9 23 

Died 4 6 10 

Whole number of patients, from 1824 . .1625 814 2439 

Eecovered 905 

Died ......... 936 



Causes of death the past year. — General paralysis, 2 ; maniacal exhaustion, 
2 ; hypertrophy of heart, 2 ; phthisis, 3 ; cancer of the breast, 1. 

We have never had the pleasure of visiting the institution the report of which 
is before us. It is among the six or seven oldest establishments for the insane 
in the United States. Its original construction was very defective ; its early 
management apparently such as might be based upon the proposition to furnish 
custodial arrangements at the cheapest possible rate. Under these circum- 
stances it is gratifying to find that Dr. Chipley, in addressing the Board of 
Managers, can now hold the following language : — 

"To you, gentlemen, I am indebted for your countenance and support in 
every effort I have made to elevate the character and to increase the comforts 
and usefulness of the institution. It has been an arduous and protracted strug- 
gle ; but I am happy now to have it to say that under your management, and 
the fostering care of generous legislation, the hospital has reached a point where 
it may safely challenge comparison with any of the many excellent institutions 
in our country. Many of them have more magnificent buildings, but none of 
them enjoy more of the substantial and essential comforts and blessings afforded 
by such institutions." 



224 



Bibliographical Notices. 



[July 



5. The records of the Central Ohio Lunatic Asylum furnish the following 



items for the last fiscal year : — 

Men. Women. Total. 

Patients in the asylum, November 1, 1859 . . Ill 103 214 

Admitted in course of the year .... 98 110 208 

Whole number 209 213 422 

Discharged, including deaths . . . . 86 84 170 

Remaining, November 1, 1860 . . . . 123 129 252 

Of those discharged, there were cured 54 47 101 

Died 7 7 14 



The diseases terminating fatally are not mentioned, and the numerous tables 
of statistics formerly included in the report from this institution are all omitted. 

It is stated that, in the course of the past year, mechanical means of bodily 
restraint has been used in but one instance, and that was "in a surgical case, 
confining a patient to a chair for short periods, on account of very sore feet." 

During the colder half of the year, one evening in each week is devoted to a 
lecture, generally illustrated by the magic lantern, and another evening to danc- 
ing. The lectures are delivered by Dr. D. L. Ely, the senior assistant physician. 

6. The report from the Southern Ohio Lunatic Asylum is brief, and contains 
but little which would be interesting to the readers of the Journal. The pro- 
fessional matter is restricted almost exclusively to the usual numerical tables. 



Men. Women. Total. 

Patients at the beginning of the year 83 73 156 

Admitted in course of the year .... 60 67 127 

Whole number 143 140 283 

Discharged, including deaths .... 61 65 126 

Eemaining, November 1, 1860 .... 82 75 157 

Of those discharged, there were cured 37 27 64 

Died ......... 6 2 8 



"The number of books has been considerably increased during the past year. 
The reading room and library now form quite an attractive place of resort for 
many of the patients." 

Dr. Atcllhenny recommends an enlargement of the building, on the^ ground 
that the present accommodations are inadequate to the necessities of the people 
of that district of the State which is allotted to this institution. 

7. The principal numerical results at the Indiana Hospital for the Insane, 
for the fiscal year ending October 31, 1860, are as follows: — 



Men. Women. Total. 

Patients at the beginning of the year . . 149 154 303 

Admitted in course of the vear .... Ill 110 221 

Whole number 260 264 524 

Discharged, including deaths 108 119 227 

Eemaining at the end of the year . . . 152 145 297 

Of those discharged, there were cured 49 55 104 

Died 19 10 29 

Admitted, from opening of hospital, 1848 . . 994 980 1974 

Discharged recovered 459 464 923 

Died 147 



Died, the past year, from maniacal exhaustion, 5; phthisis pulmonalis, 4; 
apoplexy, 2 ; suicide, 2 ; tabes mesenterica, 2 ; disease of heart, paralysis, oeso- 
phagitis, and "empyema." 1 each. 

" The general health of the patients and employees has been unusually good. 
The sanitary and police regulations of the hospital have been strictly insisted 
upon, and to this steady adherence may be attributed much of the success of 
the institution. Timely medication may very materially assist the physician 
in the restoration of insane patients, but without due regard being constantly 



1861.] American Insane Hospital Reports. 225 

had to all those laws of health involved in sleeping, dieting, and the exercise of 
the physical powers, medicine might as well be dispensed with, and the invalid 
left to the efforts of nature." 

The library was enlarged, in the course of the year, by means of a legislative 
appropriation. 

Dr. Athon calls the attention of the General Assembly to the fact that, as 
epileptics are not admitted into the asylum, no provision for their treatment has 
been made by the government of the commonwealth. He advises the introduc- 
tion of gas for lighting the apartments, and again urges the enlargement of the 
building. 

Aside from the numerical tables, this report is almost wholly devoted to the 
finances and the materiel of the institution. 

8. From the report of the Illinois State Hospital for the Insane, it appears 
that the buildings of that institution are wholly inadequate to the demand for 
accommodations. Although a general knowledge of the crowded condition of 
the hospital existed, yet the applications were threefold the ability to admit. 
The extension of the buildings which was in progress at the time of the last 
preceding report, "was arrested when midway toward completion," and "the 
completed portions (of that extension) have for two years been kept vacant." 
The cause of this action, or, rather, cessation of action, is not mentioned. 

Men. Women. Total. 



Patients in the hospital, December 1, 1858 . 229 
Admitted in the course of two years . . . 174 149 323 

Whole number 552 

Discharged, including deaths .... 321 

Eemaining, December 1, 1860 .... 231 

Of those discharged, there were cured . . 154 

Died 29 



Causes of death. — Exhaustion from long continued mania, 10 ; exhaustion of 
acute mania, 6 ; consumption, 6 ; typhoid fever, 6 ; epilepsy, angina pectoris, 
ulcer, and suicide, 1 each. 

"As usual, the great proportion of deaths has been from that natural termi- 
nation of insanity, which, for want of any distinct appellation, is termed 'mania- 
cal exhaustion.' It is subject of frequent remark that the insane in our institu- 
tions are less liable to physical disease of acute character than any other given 
number of individuals. This is only true as it regards fevers and diseases of a 
purely inflammatory character. The regularity of diet and habits of repose, 
and the evenness of temperature secured by steam heating, are unquestionably 
favourable to the prevention of acute disease. Within the last six months, the 
first striking exception to this rule has occurred known in our experience. In 
the month of June last, cases of typhoid fever began to make their appearance 
in the western, or female division of the hospital. Gradually becoming more 
marked, in the number as well as violence of the cases, it reached its highest 
degree of intensity in the month of August, when about twenty individuals, in- 
cluding several of the officers and attendants, were at one time prostrated by it. 
During the course of the epidemic, about thirty cases occurred, three of which 
proved fatal. Considering that our whole household numbered nearly three 
hundred individuals, in the most imminent state of exposure, and with constitu- 
tion especially open to the reception of the virus, we may regard ten per cent, 
of cases, and one per cent, of deaths, a small tribute to this sometimes remorse- 
less visitant. This favourable result was solely due to the prompt isolation of 
the affected cases, happily made very complete in the wards of the unoccupied 
wing. Those who died were all subjects of incurable mental disease. It is sug- 
gestive that all these cases but four were in one division of the institution ; and, 
of the four exceptions, two were officers brought into contiguity with the sick 
in the discharge of their duties. It seemed to be clearly contagious, as proven 
by several curious facts shown in the course of the epidemic. It was unques- 
tionably caused by the mephitic exhalations from the subterranean sewers which 
drain the division to which it thus especially confined itself." 
No. LXXXIIL— July 1861. 15 



226 



Bibliographical Notices. 



TTe rarely meet with three consecutive sentences containing three truths of 
so great importance as those of the subjoined paragraph. 

"We believe that success, in the treatment of the insane, largely depends on 
the ability to engage every mind in some sort of employment or recreation. 
The doctrine that insanity, even when unconnected with palpable physical dis- 
ease, is to be treated by the appliances of the apothecary's art merely, belongs 
to a bygone age. Hence, no means is to be despised that will draw' any mind 
from its morbid contemplations." 

It is not to be doubted that the system of moral treatment pursued at this 
institution is as liberal and comprehensive as the funds or means devoted to 
that object will permit. After alluding to the employment furnished to the 
patients on the farm and garden, in the dairy, the kitchen, the laundry, the 
bakery, and the carpenter's shop, Dr. McFarland proceeds as follows : — 
* •• In the winter season, mattress making and mat braiding, both involving con- 
siderable labour in the preparation of material, are excellent methods of engag- 
ing the attention of many who would otherwise find the time hang heavily. For 
indoor amusement, books, newspapers, games of chance and skill, with an occa- 
sional social reunion, at which large numbers of the insane, of both sexes, with 
their attendants, join for a few hours in temperate festivities, are all relied upon, 
and each commends itself to some especial class. Yet. after enumerating all 
the ordinary recreations in use to while away the monotony of hospital life, the 
list would be radically deficient if no mention was made of what is, after all, the 
most unfailing of all entertainments — the mutual attrition of minds so abound- 
ing in angularities and eccentricities that thought assumes shapes grotesque 
enough to amuse the gravest auditory. No one can be long in an institution 
for the insane without perceiving that the influence of insane persons upon one 
another is generally good, notwithstanding excitements among them are to a 
degree contagious. 

" Some of the most salutary influences have been proved to have arisen from 
the contemplation by one insane person of another in a still worse condition. 
But the most striking of these mutual influences is produced by the entrance of 
some new-comer, who brings into the common social stock some accomplish- 
ment of novel kind, or some new 'sensation' idea, by which he can make himself 
conspicuous. The gentleman who could utter vocal sounds from his throat 
nearly resembling the strains of an JEolian harp was for some months as good 
as an ever-present instrument of agreeable music. One gentleman, of fine edu- 
cation and much general intelligence, with a singular mental activity, has kept 
those about him for months together on the high wave of interest at a scheme 
for founding ' the Eepublic of Pomona in the South Orkney Islands.' From the 
first conception of this plan to its present complete development, every depart- 
ment of art and science in any way contingent to it has been discussed with a 
thoroughness that has been quite exhaustive. The disquisitions pronounced 
upon geography, navigation, purveyance, political economy, municipal govern- 
ment, and state religion, would have done no discredit to the author of the New 
Atlantis. These spontaneous sources of interest are sometimes better than any 
set entertainment." * * * * 

" Among the agreeable incidents of the past two years we place prominently 
a visit from Miss D. L. Dix, in the summer of 1859. The spirit which actuated 
this philanthropic lady in setting on foot the measures which led to the estab- 
lishment of this institution was, on this late occasion, found to be still as active 
as ever. Appealing in person to the liberality of those benevolent citizens in 
whom this community happily abounds, a fund of several hundred dollars was 
raised and placed in the hands of a committee, which, having been remitted to 
her, resulted in the purchase of a library of about 250 volumes, some fine stereo- 
scopes, and a large collection of engravings, which, being framed at the institu- 
tion, are scattered, with liberal profusion, about the patients' wards and sleeping 
rooms." 

It will be recollected that, on former occasions, the subject of the treatment 
of insane prisoners in the ordinary hospitals has been pretty fully discussed, and 
the arguments of several medical superintendents against the practice presented. 
Dr. McFarland here gives his views, closing in the following language: — 



1861.] 



Dean, Microscopic Anatomy. 



227 



" As all are liable to the sad visitation of insanity — the person of refined and 
sensitive nature as well as others — and as the radical principle of all insane 
hospital treatment is that of regulated association of numbers together, this 
subject cries loudly for the aid of the philanthropic legislator. Now. while the 
penitentiary at Joliet is in process of construction, is the time when this reproach 
should be taken away from this institution. Every prison, of course, has its in- 
firmary, and it only needs the attachment of some rooms of greater strength to 
give such cases of insanity as may arise comfortable accommodation. Then, 
the repeal of any act authorizing the transfer of such cases would forever remedy 
the evil. Either this must be done, or the ends of justice and the designs of 
philanthropy must continue to be infringed. 

"The subject reduces itself to the plain question: ' Which is the more -pro- 
per, to have a hospital attached to a penitentiary, or to have a penitentiary 
attached to a hospital?' The former is a necessity in all instances, a humane 
juxtaposition, which should never be wanting : the latter is a needless incon- 
gruity, corrupting to the whole employed corps of the hospital, and, if suffered 
to continue, would surely be eventually regarded as a reproach upon the ruling 
sentiment of the State." 

We perceive in this report an error in the estimation of the net value of the 
productions of the farm, such as we have heretofore noticed in several of the 
reports of similar institutions. Among the items of those productions are. corn 
$1931, hay 81225. and milk 6-4672. Now it is to be presumed that a large part 
of the corn and hay were expended in the production of the milk. Hence the 
value of all that was so expended is reckoned twice, making the profit or income 
too large by the amount of that value. P. E. 



Art. XYII. — llicroscopic Anatomy of the Lumbar Enlargement of the Spinal 
Cord. By J. Deax. M. D.. communicated to the Amer. Acad, of Arts and 
Sciences, by Prof. J. Wyman, Nov. 14, 1860. Cambridge, 1861 : pp. 21. quarto, 
with 4 plates. 

The substance of this very creditable memoir will readily be gathered from 
the following conclusions at which the author arrives : — 

"1. That true nerve cells exist only in the gray substance, these cells being 
connected by their processes in more or less definite groups ; but not probably, 
as some authors maintain, so as to form an uninterrupted chain from brain to 
filum terminate. 

" 2. That the anterior roots arise partly from nerve cells, another portion being 
directly continuous with the posterior roots. A part of the posterior roots 
also enter cells. 

•'3. The roots may therefore be divided into three classes: 'such a division 
does not, however, imply any functional difference.' 

" (1.) Anterior and posterior roots which arise from or terminate in anterior 
or posterior cells. 

" (2.) Anterior and posterior roots which meet in cells near the central part 
of the gray substance. 

" (3.) Anterior and posterior roots which are directly continuous. 

"4. That bundles of anterior roots are connected with those above and below, 
by looped fibres proceeding from cells which some of the roots enter; these 
fibres leaving the gray substance, and passing sometimes upwards, sometimes 
downwards through the anterior columns, finally curving inwards to join some 
other bundle of anterior roots with which they pass into the gray substance. 

" 5. That thus fibres from nerve cells, after passing upwards through the longi- 
tudinal white columns, do not all continue onwards to the brain, but most of 
them re-enter the gray substance at a greater or less distance from the point of 
exit, sometimes probably becoming again connected with cells, and again emerg- 
ing from these as longitudinal fibres. 



228 



Bibliographical Notices. 



[July 



" 6. That the processes from a single nerve cell, whether in the anterior or 
posterior cornu, do not necessarily all pass into the same bundle of roots, but 
often pass into three or four different bundles ; a cell process also sometimes 
sending branches into different bundles. Thus we may have sensitive impres- 
sions from different parts of the surface conveyed to one cell, and motor im- 
pulses distributed from one cell to different points. 

"7. That all the anterior and probably all the posterior roots enter the gray 
substance, though the posterior roots often pass into the cornu at a considerable 
distance from their first entrance into the cord. 

"8. That most of the fibres from the posterior roots, after traversing the 
posterior columns, are collected into transverse bundles, traversing the sub- 
stantia gelatinosa in a slightly ascending course, after passing through which 
they curve downwards (sometimes upwards), forming, by the longitudinal course 
which they then maintain for some distance, a very interesting series of longitu- 
dinal bundles, which I have called longitudinal columns of the cornua, standing 
in a very close relation to the posterior vesicular columns of Clarke, with the 
cell processes of which many of their fibres are continuous. 

" 9. That some of the bundles which traverse the substantia gelatinosa do 
not pass into the longitudinal columns of the cornua, but proceed directly across 
the gray substance, becoming continuous with the anterior roots. 

"10. That the posterior white columns are composed almost entirely of the 
posterior roots, which merely traverse them before entering into the gray sub- 
stance. They appear, however, to receive a few fibres from cells situated on the 
extreme margin of the posterior cornua, and some more or less longitudinal 
fibres from the looped recurrent bundles. 

" 11. That the posterior roots are connected by curved fibres or bundles of 
fibres, proceeding from one root and curving round after penetrating the gray 
substance, becoming connected with some other root above or below. The same 
is seen in transverse sections with regard to roots situated side by side, both 
anterior and posterior, the looping fibres sometimes proceeding directly from 
root to root, and sometimes passing through cells. 

"From which it results that the same fibre must in different parts of its course 
conduct both centrifugally and centripetally. 

" 12. That, besides the looped recurrent fibres, the three principal courses 
taken by the posterior roots before entering the gray substance are with refer- 
ence to a longitudinal plane, ascending oblique, descending oblique, and trans- 
verse." 

We have thus presented Dr. Dean's conclusions, embodying as they do the 
gist of his paper. We cannot go into the elaborate task of discussing them in 
this place, and showing how far they agree with the opinions of other investiga- 
tors, and in what they differ from them, though in a general way we may remark, 
they agree best with the opinions of J. S. Clarke. 

Suffice it to say that the paper is the evidence of an honest attempt to work 
out a most difficult problem, of the highest physiological importance. And that 
if, after its perusal, we are still compelled to regard the course of the nerve fibres 
in the spinal cord, and their relations to the nerve cells, as among the unsettled 
problems, which minute anatomy has as yet incompletely answered, we do so 
with a full appreciation of the value of Dr. Dean's effort, and with the hope that 
he will persevere in the difficult and honourable investigation upon which he has 
made, what every one who knows by experience the difficulties of the subject 
must regard as a most creditable and praiseworthy beginning. As a matter of 
some interest we subjoin in full the mode of preparation employed by him in 
the studies. 

"The method of preparation usually employed was a modification of G-erlach's 
and Clarke's, although many others were employed, according to the object in 
view. The following method gave the best result from which to make drawings. 
Thin sections from the cord, hardened in alcohol, were washed a few minutes in 
pure water, and then immersed in glycerine to which Gerlach's solution of car- 
mine, 1 previously filtered, had been added; in this the sections were allowed to 

1 Solution of carmine in water, to which a few drops of strong ammonia have 
been added. 



1861.] 



Mitchell, Yenom of the Rattlesnake. 



229 



remain 4 or 8 hours, according to the tint desired (a light tint interfering least 
with the details and sharpness of outline). I have been able to obtain more 
delicately coloured specimens, and more clearly denned structure by the use of 
glycerine than by any other method. The sections are then washed first in pure 
water, afterwards in strong alcohol, in which they are allowed to remain about 
an hour, and are now ready for preparation with turpentine, according to Clarke's 
method; they may be put up in Canada balsam, or, as I have found very advan- 
tageous, in thick colourless copal varnish, which often preserves minute details 
better than balsam ; although Stilling and others have found much fault with 
Clarke's method of preparation, on account of the too great transparency it 
sometimes gives, I am convinced that, with practice and some slight modifica- 
tions, it is the only one suited to the minute study of the cord, other methods 
seeming to me, after thorough trial, quite unsatisfactory as compared with 
Clarke's. As a hardening material, I have often employed chronic acid with 
considerable advantage ; but when colouring matter is used, alcohol is most 
suitable, and is certainly much easier to succeed with." 

In conclusion we may bestow praise on the four plates which illustrate the 
memoir, and which we are told were etched upon the copper by the author 
himself. They are evidently faithful likenesses of the preparations from which 
they are drawn, which more than counterbalances any little want of artistic 
elegance in their execution. J. J. W. 



Akt. XVIII. — Researches upon the Venom of the Rattlesnake ; with an Inves- 
tigation of the Anatomy and Physiology of the Organs Concerned. By S. 
Weir Mitchell, M. D., Lecturer on Physiology in the Philadelphia Medical 
Association. Published by the Smithsonian Institution, January, 1861. Pp. 
145. With twelve wood-cuts. 

The industry, perseverance, and experimental skill displayed in this mono- 
graph reflect much credit upon the author. From the preface we learn that 
'• during a large part of two years he has given to this work almost all the 
leisure which could be spared from the everyday exactions of his regular pro- 
fessional duties." 

The essay is divided into seven chapters. The first contains some general 
observations upon the habits of the Crotalus when in captivity. In the second 
is described the anatomy of the venom apparatus. The third treats of the 
physiological mechanism of the bite of the Crotalus. The fourth is devoted to 
the consideration of the physical and chemical characters of the venom. In 
the fifth, sixth, and seventh chapters, the toxicology of the venom of the Crotalus 
is considered. Chapter eighth treats of Crotalus poisoning in man. 

The last four chapters more particularly commend themselves to the practi- 
tioner of medicine, who is occasionally called upon to treat cases of rattlesnake 
bite and its dreadful constitutional effects. 

From his numerous experiments upon different animals, Dr. Mitchell con- 
cludes — 

" 1st. That the heart becomes enfeebled shortly after the bite. This is due 
to direct influence of the venom on this organ, and not to the precedent loss of 
the respiratory function. Notwithstanding the diminution of cardiac power, 
the heart is usually in motion after the lungs cease to act, and its tissues remain 
for a time locally irritable. The paralysis of the heart is, therefore, not so com- 
plete as it is under the influence of upas or corroval. 

" 2d. That in warm-blooded animals artificial respiration lengthens the life of 
the heart, but does not sustain it so long as when the animal has died by woorara 
or decapitation. 

3d. That in the frog the heart-acts continue after respiration has ceased, 
and sometimes survive until the sensory nerves and the nerve-centres are dead, 
the motor nerves alone remaining irritable. 



230 



Bibliographical Notices. 



[July 



" 4th. That in warm-blooded animals respiration ceases, owing to paralysis of 
the nerve-centres. 

" 5th. That the sensory nerves, and the centres of nerve power in the medulla 
spinalis and medulla oblongata, lose their vitality before the efferent or motor 
nerves become affected. 

" 6th. That the muscular system retains its irritability in the cold-blooded 
animals, acutely poisoned, for a considerable time after death. 

" 7th. That the first effect of the venom being to depress the vital energy of 
the heart, and nerve-centres, a resort to stimulants is clearly indicated, as the 
only rational mode of early constitutional treatment." 

With regard to the condition of the blood in cases of Crotalus poisoning, the 
author informs us "that in animals which survive the poisoning for a time, the 
blood is so altered as to render the fibrin incoagulable. Experiments in and 
out of the body have given proof that this change is gradual, and that the 
absence of coagulation is not due to checked formation of fibrin, but to altera- 
tions produced by the action of the venom in that fibrin which already exists in 
the circulating blood. The influence thus exerted is of a putrefactive nature, 
and imitates in a few hours the ordinary results of days of change. It is 
probably even more rapid within the body, on account of the higher tempera- 
ture of the economy. The altered blood retains its power to absorb gases, and 
thus to change its own color. The blood-corpuscles are unaffected in acute 
poisoning by Crotalus venom, and are rarely and doubtfully altered in the most 
prolonged cases which result fatally. The contents of the blood-globules of the 
guinea-pig can be made to crystallize, as is usual after other modes of death." 

Concerning the antidotes to be employed, or the mode of treatment to be 
instituted for the purpose of counteracting the deadly effects of the rattlesnake 
venom, Dr. Mitchell's researches afford us no satisfactory information. After 
criticizing and throwing doubt upon the efficacy of the various remedies from 
time to time recommended for the cure of Crotalus poisoning, he says: — 

" When a person has been bitten, it would be proper slightly to intoxicate 
him, then to loosen the previously applied ligature or cup, and, watching the 
pulse, and relaxing or tightening the ligating cord, to control thus the inlet of 
the poison, with the aid of the stimulus destroy its effects in detail. Finally, 
the stimulus should be most cautiously and by degrees abandoned, with con- 
tinued regard to the state of the system." 

"It sometimes happens," he continues, "that the physician finds it impossible 
to produce stimulation in the presence of so potent a sedative as the venom. 
When this is the case, it is possible that absorption does not occur with suffi- 
cient rapidity, or, at all events, that cases may occur where it is necessary to 
stimulate fully and suddenly. 

" Under these circumstances, I would recommend inhalation of the fumes of 
warm alcohol, or even of ether, if used with caution. 

" While advocating the employment of stimuli as rational therapeutic means 
of meeting a most obvious indication, it is proper to admit that cases have been 
and will be encountered, in which the dose of venom has been so great that no 
remedy is of any avail. Such, however, must be rare, and it is, on the whole, 
more than probable that the danger from the bite of the rattlesnake has been 
over-estimated, and that in a large majority of cases the patient would recover, 
even if unassisted by any remedy. 

" Where stimulants are of any use, the patient commonly recovers without 
any difficulty. In some cases, however, which attain to the stage of alteration 
in the blood, we have to deal with conditions which are also present in other 
cases of putrefactive poisoning, but for which we have no remedies of well- 
determined power. Possibly, tonics, astringents, and continued stimulation 
might be of some value in supporting the strength until the blood recovers its 
normal condition." 

A copious bibliographical record of the subject, derived chiefly from Soubei- 
ran's Bibliography, is appended to the " Researches." Another appendix con- 
tains " An Enumeration of the Genera and Species of Rattlesnake, with Synonymy 
and References," by Mr. E. D. Cope. J. A. M. 



1861.] Maxon, Treatise on the Practice of Medicine 231 



Art. XIX. — A Treatise on the Practice of Medicine. By Edwin R. Maxon, 
M. D., Formerly Lecturer on Institutes and Practice of Medicine in the Geneva 
Medical College. 8vo. pp. 705. Philadelphia: Lindsay & Blakiston, 1861. 

A careful perusal of this work has impressed us with strong doubts as to 
Dr. Maxon having acted very wisely in acceding to the solicitations of the 
members of his class for the publication of the present volume. He seems to 
us to have mistaken his vocation when he undertook to write a treatise on the 
practice of medicine. The avowed design of the author is to produce as original 
a work as one of the kind can well be rendered. In this we cannot think that he 
has succeeded, and, so far as we are able to discover, the treatise supplies no 
existing want in our native medical literature. In neither the accuracy and ful- 
ness of its pathological and therapeutical teachings, the extent and value of the 
personal observations and deductions embraced in it, nor the excellence and clear- 
ness of its style can it compete with the practical systematic treatises already in 
our possession. Nor can it rank with these simply in the character of a useful 
additional exponent of the theory and art of healing, which, while it carries its 
readers over the same ground, directs their attention to points of interest which 
others have, perchance, but imperfectly explored, or invests with a new interest 
and importance, some which already have become familiar. 

It cannot be recommended as a safe and useful guide for the student, still less 
as a work of reference from which the busy practitioner, on an occasion of 
emergency, can derive the information he may want ; in both of which characters, 
however, it is offered by its author. 

The treatise of Dr. Maxon is strictly and almost exclusively dogmatic. The 
author but rarely condescends to examine and attempt to reconcile any appa- 
rent contradiction which may exist in the observations upon record bearing 
upon the pathology or treatment of particular diseases. The simple assertion 
" it seems to me," he would appear to deem sufficient for the settlement of all 
difficulties, and to establish as truths whatever views he propounds in reference 
to the causes, seat, and nature of diseased action — whatever plan he lays down 
for its modification or arrest. 

The great defect in the work before us, whether as a manual to supply the 
wants of the medical student, or as a remembrancer of the leading facts and 
principles of the theory and practice of medicine for the use of the physician, is 
not so much, perhaps, in the erroneous teachings, generally speaking, of the 
author, as in their extremely superficial and incomplete character. Some of the 
most important and intricate questions connected with the causation, character, 
and management of certain of the morbid conditions to which the human organ- 
ism is liable — questions that have occupied much of the attention of medical ob- 
servers, and in reference to which a vast amount of facts and observations have 
been accumulated — are passed over without the slightest notice, or are examined 
in so concise a manner that the reader is left without any accurate idea of the 
real state of our knowledge in respect to them ; while others, again, involving 
wide differences of opinion among some of the most erudite and experienced 
members of our profession, are treated with a dogmatism that is only excusable 
in reference to what are universally recognized as established truths. Further, 
the style of the work is as deficient*in precision and elegance as it is in accu- 
racy, and is throughout disfigured by grammatical blunders. As an excuse for 
the defects of style, Dr. Maxon pleads want of leisure for their correction. A 
plea very rarely valid, and altogether inadmissible where the author, as in the 
case before us, is under no necessity of publishing before he is fully prepared to 
execute his task in a proper manner. 

In conclusion, we regret to have to add that though the volume is handsomely 
got up in respect to its mechanical execution, it is full of errors of the press, 
many of them being of a particularly annoying character. 

D. F. C. 



232 



Bibliographical Notices. 



Art. XX. — Report of Professor Valentine Mott's Surgical Cliniques in the 
University of New York, Session 1859-60. By Samuel W. Francis, Mem- 
ber of Dr. Mott's Surgical Staff. S. S. & W. Wood, 1860 : 12mo. pp. 204. 

The object of this exceedingly well printed and elegantly got up little 
volume, we are told in the preface, is "to preserve in a durable shape some of 
the aphorisms of one whose experience is as vast in the practice of surgery as 
his reputation is great in the eyes of his countrymen." It contains a report 
by the author of the remarks made by Professor Valentine Mott upon some 
ninety cases, which presented themselves at his surgical clinique in the course 
of a winter. 

Well drawn up reports of the clinical lectures of eminent medical men form 
not only a very instructive, but a very interesting and agreeable portion of the 
literature of our profession, and judging from the number of such reports pub- 
lished both in separate volumes and in medical periodicals, it is, moreover, a 
portion of our literature which is very highly appreciated. 

The reputation of Dr. Mott is great, not only "in the eyes of his countrymen," 
but everywhere where great surgical achievements are known and' honoured, 
and his clinical lectures, being the result of extensive experience, will no doubt 
be read with very considerable interest, both in this country and abroad. 

We regret, however, to have to say that this work is disfigured by very nu- 
merous typographical errors and by peculiarities of style, which, by a reasonable 
degree of care on the part of the editor, would have been readily avoided. For 
instance, we read : "mercury had been administered together with a few general 
hygienic rules ;" " stimulants must be freely given and plenty of fresh air, together 
with the proper hygienic principles of therapeutics." "The boy's health began 
rapidly to decline, and his parents apprehending a prolonged dissolution." " The 
slow, torturing, exsiccating, gnawing pains of a cancer." " When a cicatrix has 
resulted in what the French term ' contracteur.' " "Why cancer should always 
affect the lower lip, and Hare lip likewise with as certain accuracy involve the 
upper lip, are paradoxes that must be classed among the unexplained phe- 
nomena." "Caries of the vertebras are." "When caries of the spine have 
been." "Five days before New Years last; " gluetei muscles, sinovitis, lucoma, 
epiphasis, etc. etc. The prescriptions are also most carelessly written. We read : 
Aquae Bulient. ; Extr. Hyosiami; Melis; Tinct. ferriiodidi; Hydrarg. Sub. Mu- 
riat; Liquor Potassa et arsenit. ; &c. &c. One of them, to give a specimen 
entire, is as follows : R. ; Quinin. Super Sulphat. gj. ; Aromat. Sulphur. Acet, 
3ij. ; Zinzer. Syrup, ^vij. ; M. 

Surely errors such as these are altogether inexcusable. W. F. A. 



Art. XXI. — Guy's Hospital Reports. Edited by Samuel Wilks, M. D., and 
Alfred Poland. Third Series, Yol. YI. London : 1860. 8vo. pp. 531. 

The present volume of this valuable publication contains seventeen original 
communications, one wood-cut, and nine lithographic plates. The following is 
an analysis of its contents : — 

I. On the Surgical Diseases and Injuries of the Nose, Larynx, Thorax, with 
its contents, and of the Organs of Circulation. By Thomas Bryant. 

In the last volume of Reports Mr. Bryant published the first of a series of 
articles, intended to illustrate, from cases that have occurred in Guy's Hospital, 
the surgery of the different regions of the body. That article, upon the injuries 
and diseases of the nervous system, was very satisfactory. 

In the present paper, under the head of diseases and injuries of the nose, Mr. 
Bryant speaks only of foreign bodies in the nose, of polypi, and of ozaena. For 



1861.] 



Guy's Hospital Reports. 



233 



the removal of foreign bodies, we are told to place the patient, who is generally 
a child, under the influence of chloroform, and to use a hook-bent probe, or a 
pair of forceps. No mention is made of the application of a pinch of snuff, or 
of black pepper, a proceeding much less terrifying to the child, and one that 
often succeeds, by the paroxysm of sneezing produced, in dislodging the ob- 
structing body. 

For the removal of the softer kinds of polypi, Mr. Bryant, in common with 
almost all surgeons, prefers abruption, which he performs by means of a noose 
of wire instead of a pair of forceps. In regard to the firmer and fibrous forms 
of polypi, he says that they appear to grow from the upper and posterior portion 
of the nasal cavity; if they grow forward, the nose may be slit up and the growth 
removed, either by excision, ligature, or both ; if they press backwards down the 
pharynx, means adapted to the requirements of the case, calculated to procure 
a like end, must be employed ; the soft palate may require division, but such a 
practice should not be performed unless absolutely essential. The anatomical 
origin of these fibrous polypi, and the methods by which they require to be 
attacked, are not by any means well set forth in this description. Almost inva- 
riably these fibrous polypi, projecting into the nasal passages from their meeting 
in that direction with least resistance to their growth, spring from the anterior 
surface of the basilary process ; they are in fact vegetating periosteum, enor- 
mous hypertrophy of the fibrous membrane covering that portion of the base of 
the cranium. To thoroughly eradicate them it is necessary, as we have several 
times witnessed ourselves, not only to divide the soft palate, as Mr. Bryant says, 
but to remove the whole bony palate, or, what some surgeons prefer, to remove 
an upper maxillary bone. For malignant polypi we are advised to pursue a like 
treatment to that recommended in the fibrous ; no other account of them is 
given. For chronic inflammation and thickening of the mucous membrane of 
the nose, particularly that portion covering the inferior turbinated bone, which 
sometimes is mistaken for polypus, constitutional treatment, in the form of tonics, 
is advised, as being generally all that is required. Bemoval of the turbinated 
bone Mr. Bryant would hesitate to practise. Constitutional remedies, however, 
are, we know, not always sufficient to relieve the patient ; and the removal of a 
portion of the lower turbinated bone, for which the ordinary scissors of a pocket- 
case are all that is required, should then be practised. 

The offensive smell of the discharge from the nose in ozaena, Mr. Bryant be- 
lieves to be owing entirely to decomposition of the retained muco-purulent secre- 
tion, and that the free use of a syringe is all that is requisite to rid the patient 
of that most troublesome symptom. Cleanliness locally, with tonics constitu- 
tionally, comprise his treatment ; topical stimulants, such as the sulphate or 
chloride of zinc, or the nitrate of silver, in the strength of about one grain to 
the ounce of water, are employed when simpler means have failed. 

Eighty examples of foreign bodies in the air-passages are given. Five of the 
cases were three years old and under, and three between the eighth and ninth 
year. In all tracheotomy was performed ; in five, the foreign body was ejected 
immediately upon the opening of the trachea, and all of these cases recovered 
but one that died on the eighth day of broncho-pneumonia. In the three cases 
where the foreign body could not be removed death ensued, the foreign bodies 
in those cases being a bean, a piece of bone, and a nut-shell. Several practical 
points are presented from the consideration of these cases ; if the body is soft 
and likely to become swollen and enlarged, or pointed and rough so as to irritate 
the bronchial membrane, the operation should be at once performed ; if the body 
refuses to move, after an opening has been made in the windpipe, the opening 
should not be closed, in order that the body may be ejected, should it become 
displaced by some fortunate act of coughing; and the third point is to examine 
the larynx carefully by passing a probe upwards through the wound, and the 
finger downwards through the mouth. The fatal result in two of the cases seems 
very evidently to have been the result of the neglect of the second and third 
points just mentioned. 

GEdema of the larynx from swallowing boiling water is another condition 
quite often requiring tracheotomy in England. The poor in that country have 
the habit of feeding their children out of a teapot, and the children in conse- 



234 



Bibliographical Notices. 



[July 



quence not unfrequently go to the kettle on the fire to get a drink of their food. 
(Edematous inflammation of the pharynx and orifice of the larynx is the result. 
Mr. Bryant cites twelve examples of such an accident, all taking place in chil- 
dren under three and a half years of age. In nine cases tracheotomy was per- 
formed ; in five of these with success, in the remaining four a fatal result ensued. 
In regard to scarifying the cedematous mucous membrane, Mr. Bryant says that 
it has lately been suggested by surgeons, but that he has no personal experience 
to give upon the matter ; adding, moreover, that if it can be done with facility 
and success, the propriety of such a measure cannot be doubted. 

A frequent cause of death in all the cases of tracheotomy related by Mr. Bryant, 
both those in which the operation was performed on account of the inflammation 
produced by a scald and those where it was performed to facilitate the extrac- 
tion of a foreign body, was broncho-pneumonia. One cause aiding considerably 
in producing this affection, he says, is the irritation of the milk or other food 
which finds its way into the air-passages on account of the imperfect closure of 
the orifice of the larynx. To remedy this he proposes to feed the child through 
a tube passed down into the oesophagus. All that is necessary in these cases, 
however, is to administer semi-solid food, such as thickened soups and pounded 
meat, and to withdraw all liquids as much as possible, for these alone find their 
way down the orifice of the larynx. A principal cause of the broncho-pneumonia 
observed after tracheotomy, and one not referred to by Mr. Bryant, is the exter- 
nal air passing directly into the trachea, without having been previously warmed 
by passing through the nose, mouth and fauces. The use of the cravat recom- 
mended by Trousseau, a large woollen comforter loosely fastened around the 
throat, is calculated to produce a good effect, and should always be practised. 
A point worthy of remark in regard to the situation of foreign bodies that have 
entered the bronchi is, that Mr. Bryant states the left bronchus to be their most 
common seat. This is at variance not only with the anatomy of the parts, but 
also the almost uniform experience of surgeons. 

Of wounds of the throat thirty-six instances are given; in fourteen, the nature 
of the injury inflicted being severe. In their treatment, Mr. Bryant does not, as 
many surgeons, reject entirely the use of sutures, but declares them to be of 
immense benefit in large wounds, where the parts cannot be kept together. In 
following his plan, too much care cannot be taken to allow a free passage for the 
blood, the mucus, and the various secretions, and for the ingress of air. 

Of simple fracture of the ribs, Mr. Bryant possesses one hundred and eight 
examples. The plan of treatment he recommends, and which is the one usually 
employed at Guy's Hospital, is the application of long strips of thick plaster, 
about one and a half to two inches broad and long enough to extend from the 
spinal column to the sternum, each strip when applied overlying the one above 
for half its width. By this means, he says, the injured ribs are kept absolutely 
at rest, whilst those of the sound side are left free. The use of adhesive plaster 
presents many advantages, in these cases, but we have always believed it neces- 
sary to encircle the whole chest ; those w^e use are long enough to go once and 
a half around the body. On account of the influence which the recent publica- 
tion of Dr. Hamilton will necessarily have on the practice pursued in this coun- 
try in the treatment of fracture, we would here express our regret at his having 
objected to the use of adhesive plaster in these cases, giving for his reason that 
it will certainly become loosened after a few hours by the slight but uninter- 
rupted play of the ribs. It is not only the best bandage for the patient, but 
also the one most readily and easily applied by the surgeon. 

When injury has been done to the lung so extensive as to cause not only 
emphysema, but pulmonary hemorrhage, the treatment pursued by Mr. Bryant 
consists in the administration of antimony and in bleeding freely once, twice, or 
three times if necessary. In regard to the benefit to be derived from bleeding 
in these cases, his testimony is very strong ; although so opposed are they 
generally to bleeding, in Guy's Hospital, that he states it to be more rare there 
than any capital operation. 

In conjunction with these cases of fracture of the ribs with injury to the 
lung, Mr. Bryant relates a very curious case where, by the passage of the wheel 
of a cart over the trunk of a boy, seven years of age, the lower edge of the 



1861.] 



Guy's Hospital Reports. 



235 



middle lobe of the right lung was lacerated to the extent of three inches, and 
yet there was no fracture of the ribs, or any external indication of injury to the 
thorax. The possibility of laceration of the lung, without fracture of the rib, is 
a point worthy of remembrance. 

Under the head of diseases and injuries of the organs of circulation, Mr. 
Bryant treats of wounds of the arteries, of aneurism, and of naevus. Among 
the cases recorded of wounds of the arteries, are three of punctured wounds of 
the femoral, and in one of these spontaneous cure resulted. There is of course 
always room for doubt as to whether the femoral has been really wounded, but 
in this instance, at all events, the evidence is, for us, quite sufficiently strong. 
Of lacerated wounds there are three examples, one of the axillary from a fall on 
the spike of an iron railing, and two of the popliteal, associated with and caused 
by dislocation of the knee-joint. In the laceration of the axillary there was no 
bleeding, and there was also a total absence of pulsation in any of the vessels of 
the arm. A pad was placed over the wound, and the arm kept at rest ; no bad 
symptom followed, and after five weeks he left the hospital cured, pulsation in 
the radial having returned, but none in the brachial artery. In both the cases 
of laceration of the popliteal artery, the dangers were much magnified by the 
injury received by the knee-joint. In both amputation of the thigh was per- 
formed, and both died from sinking, one a few hours, the other forty, after the 
operation. 

Of aneurism, Mr. Bryant possesses twenty examples, fifteen of which were of 
the femoral artery in some portion of its course. The chief point of interest 
in these cases, at the present moment, is the result of the effort to cure them 
by means of pressure, in those cases where pressure was applicable. In eight 
cases of popliteal aneurism, pressure was tried ; three of them were cured, and 
five were afterwards successfully treated by ligature. In two cases of aneurism, 
situated about Hunter's canal, pressure was successful in one ; in the other it 
was given up, after a short trial, for the ligature, which was successful. The 
reason given for abandoning pressure in all these cases is, that it was intolerable 
to the patient. The manner in which the pressure was applied is not carefully 
described ; a lead weight and a screw tourniquet were used ; that is all we are 
given to know. In only one case was digital pressure made use of, and in that 
case it was successful, all pulsation ceasing at the expiration of sixty hours, after 
the clamp and weight had been used without apparent advantage for five weeks. 
We feel persuaded ourselves that, by a greater exertion of patience, and, above 
all, of ingenuity in the application of pressure, a greater proportion of the cases 
would have been successfully cured by this means. 

The practice recommended by Mr. Bryant, in the treatment of ncevi, is that 
now generally adopted by surgeons. Caustics for the purely cutaneous ; the 
ligature, the seton, or injections of perchloride of iron for simple subcutaneous ; 
and the ligature or excision for those in which both the subcutaneous tissue 
and the skin are involved. His experience with the injection of perchloride of 
iron is not very satisfactory. Of twelve cases, a successful result ensued in 
seven — that is to say, the nsevus became indurated, and apparently in an inactive 
condition. In one case suppuration followed, and in four the whole tumour 
sloughed off, the inflammation excited by the injection having been too intense. 

Of wounds and diseases of the veins Dr. Bryant does not speak in this paper, 
for the reason, we hope, that he may enter more fully into their consideration in 
a future article. The table of admissions into Guy's Hospital shows a large 
number of cases of wounds of veins, of ruptured varicose veins, of local phle- 
bitis, and of thrombus. 

II. Catena of Gases illustrating the Use of Forceps in Extraction of Cata- 
ract. By John F. France. 

This communication contains the histories of twenty-one cases of cataract in 
which the operation of extraction was performed. Of these twenty-one cases, 
nineteen were successful. 

Much of his success Mr. France attributes to the use of artery-forceps to 
control the globe of the eye, during the operation, in the manner described in a 
former paper, published in vol. iv. of the Reports, an abstract of which was 



236 



Bibliographical Notices. 



[July 



given in the April number of this Journal for 1859. Desmarres, who intro- 
duced the use of artery-forceps for this purpose, declares that he has abandoned 
them for instruments mieux supports by the patient. The thimble he describes, 
or the hook of Pamard, must be decidedly less disagreeable to the patient, and 
equally advantageous. 1 

This communication is accompanied by a plate containing two figures, repre- 
senting, one the mode in which M. Desmarres used the forceps, the other the 
mode in which they are used by Mr. France. 

III. On some Diseases of Children. By Samuel Wilks, M. D. 

In the present article Dr. Wilks has brought together a large number of 
cases of the following diseases : Tubercular meningitis, tubercular disease of 
the brain-substance, simple acute meningitis, simple arachnitis, convulsions, 
chronic hydrocephalus, secondary ventricular effusion, simple ventricular effu- 
sion from anaemia, and of hydatids in the brain ; of croup and laryngeal 
affections, and of cases generally in which tracheotomy is performed, in order 
to show the dangers of that operation ; of pneumonia, bronchitis, pericarditis, 
etc. ; of cancrum oris, and of cases to show the cause of death from burns and 
scalds. Of these various affections, fatal cases, in which post-mortem examina- 
tion was made, have been selected by Dr. Wilks, so that his paper is particu- 
larly valuable, as giving their anatomical peculiarities, and as pointing out in 
what direction their fatal termination may be looked for. 

This communication, one of the most valuable in the whole volume, is of a 
kind scarcely admitting of analysis. The opinions therein expressed in regard 
to the various affections treated upon are founded upon cases that are recorded 
in great detail, and derive their importance chiefly from this connection. To 
give an analysis of all these cases is out of the question ; all that can be done 
is to state the more important opinions to which the study of these cases has 
obliged Dr. Wilks to come, and some few general conclusions. 

Tubercular meningitis, which some writers do not distinguish from acute 
meningitis, he believes may be shown to be as distinct an affection as any in the 
nosology ; so also acute simple meningitis, and acute arachnitis arising from 
external causes. Two facts, that seem now to be clearly ascertained in pathology, 
are well indicated by these cases, namely, that convulsions are dependent on the 
affection of the surface of the brain, and paralysis on softening of the central 
part. 

In cases of cerebral affection, the contracted condition of the abdomen, 
associated with a similar contraction of intestine and constipation, and the very 
general dislike to being disturbed, are points to which attention is particularly 
called. Pains in the limbs and increased sensibility of surface are also often 
observed. 

In regard to croup, Dr. Wilks believes that the membranous and the 
catarrhal forms are identical affections, the membranous exudation being due, 
not so much to any pathological peculiarity of the disease as to the anatomical 
structure of the air-tubes in children, and that this form of exudation need not 
of necessity occur, though the disposition exists always to its formation. In 
regard to tracheotomy in connection with the treatment of croup, Dr. Wilks 
does not give a decided opinion from the absence of sufficient data. As it is 
often spoken of as a harmless operation, it may be well to add that he declares 
that he believes it to be an operation of considerable hazard, and one not to be 
put in practice without deliberate reason for its necessity. He points out a 
source of danger in tracheotomy which we have never before seen alluded to, 
namely, pneumothorax arising from the escape of air from the mediastinum 
drawn into the chest from the neck. In two cases he records, the emphysema 
was confined to the chest ; in a third it was universal. 

IV. The Physiology of Sleep. By Arthur E. Durham. 

From experiments made upon dogs and rabbits, Mr. Durham is led to believe 
that during sleep the brain is in a comparatively bloodless condition; andmore- 

1 Traite Theorique et Pratique des Maladies des Yeux, tome iii. p. 183. Paris, 
1858. 



1861.] 



Guy's Hospital Reports. 



23T 



over that the blood in the encephalic vessels circulates with diminished rapidity. 
His experiments were made by removing, by means of a trephine, a portion of 
bone about as large as a shilling from the parietal region, partially cutting away 
the subjacent dura mater, and replacing the bone removed by an accurately fit- 
ting watch-glass, fastened air-tight by inspissated Canada balsam. The results of 
observations thus made, as recorded by Mr. Durham, are altogether at variance 
with the doctrine almost universally taught by physiologists, that sleep is ac- 
companied by sanguineous congestion of the brain. From its manifest bearing 
upon the point in question, it may be thought a matter of some surprise as well 
as regret, that Mr. Durham did not think of examining the condition of the 
fontanelles of infants during sleeping and waking. The degree of projection or 
depression of the soft parts covering these natural orifices in the cranium affords 
a good indication, we believe, of the vascular condition of the brain. At all 
events, other experiments and further observations are necessary before physi- 
ologists will be willing to receive his doctrine. 

After summarily announcing the result of his experiments, Mr. Durham pro- 
ceeds to argue as if the bloodless condition of the brain during sleep was an 
accepted fact, and to endeavour to show how this condition would be produced 
by causes which, he maintains, are favourable to sleep. To give an example : a 
hearty meal, a substantial supper, he says, is favourable to sound, deep sleep, and 
the reason is that during the digestive process the abdominal viscera receive a 
vastly increased supply of blood, leaving the rest of the body comparatively 
empty. Now, going to bed upon a full stomach gives one but a sorry chance 
for a quiet rest in the night ; ut sis node levis, sit tibi ccena brevis is an old say- 
ing and a true one. Again, during the digestive process we have no doubt that 
the blood circulates more rapidly over the whole body, and the bloodvessels 
everywhere are fuller. One of the aphorisms of Hippocrates is that in winter 
and in spring the abdominal viscera are naturally very warm, and the sleep very 
long [at xoi%uu ^Et^tofotf xal rjpoa dsppota'ta.i' vosc, xal vrtvoc /xaxpo'tatot). The long 
sleep, according to Mr. Darwin's doctrine, would be the result of the warmth of 
the viscera, for this would be owing to the great quantity of blood in the abdo- 
men, leaving, as a matter of course, the rest of the body, with the brain, com- 
paratively healthy. This warmth about the belly was much sought after in 
ancient days, before, however, the reason of the connection it has with sleep 
was explained: it is good, on going to bed, says an old writer, "to lie on the 
right side first, because at that site the liver cloth rest under the stomach, not 
molesting any way, but heating him as a fire doth a kettle that is put to it." 
This old explanation of the effect of position upon sleep seems very absurd to 
us : undoubtedly some of Mr. Durham's explanations will produce the same 
effect upon the minds of medical men in future years. 

The condition of the mind has more to do with sleep than the condition of the 
digestive organs. We read that when Ptolemy, king of Egypt, had posed the 
seventy interpreters in order, and asked the nineteenth man what would make 
one sleep quietly in the night, he told him, " optimum de coelestibus et honestis 
meditari, et eafacere." At the present day we could not make a better answer, 
and so practical a one is not to be drawn from the long communication before us. 

Y. Some Gases of Hydatid Disease. By S. 0. Habeeshon, M. D. 

The cases reported by Dr. Habershon are thirteen in number. In ten the 
liver was affected, in one the cellular tissue of the bladder, in one the pericar- 
dium, and in one case the hydatid cyst was situated between the stomach and 
the colon. In only one of the ten cases in which the liver was affected was any 
operation performed for the relief of the patient; in this case the contents of 
the hydatid cyst were evacuated by repeated operations with a trocar, and the 
patients recovered. 

VI. Facts and Fallacies connected with the Research for Arsenic and Anti- 
mony ; with suggestions for a method of separating these Poisons from Organic 
Matter. By Alfred S. Taylor, M. D., F. R. S. 

The method for the detection of arsenic herein recommended by Dr. Taylor, 
he believes to combine the advantages of the two tests of Marsh and Reinsch, 
and to be attended with less risk of fallacy than either process taken separately. 



238 



Bibliographical Notices. 



Marsh's process for the research for arsenic consists, as is well known, in the 
conversion of the ordinary compounds of arsenic to arseniuretted hydrogen gas, 
in a properly constructed apparatus. By its means, according to experiments 
made by Dr. Taylor, deposits may be obtained from the 2000th part of a grain 
of arsenic, in the minimum quantity of liquid required for use in Marsh's tube. 
When the weight of arsenic reaches the l-100th of a grain, the deposits admit 
of the application of corroborative tests. In using this process, however, for 
the separation of arsenic from the fluids or solids of the body, two difficulties 
are encountered. First, there is no good or simple method of bringing the 
arsenic to a concentrated state, that is, to a state fitted for testing without pro- 
ducing froth; and, secondly, when the quantity of arsenic in an organic liquid 
is so small as to render the adoption of the process necessary, it is not possible 
to follow the plan of the inventor, of generating the hydrogen in the whole 
quantity of the organic liquid. 

The process of Reinsch is singularly simple, delicate, and easy of application. 
It is founded upon the fact, accidentally discovered hy him, that when a piece 
of copper is immersed in a mixture of hydrochloric acid and water, if arsenic 
be present, it will be deposited on the surface of the metal. The l-4000th part 
of a grain of arsenious acid thus admits of detection. Antimony is precipitated 
upon copper under precisely similar circumstances ; the presence of twice the 
quantity, or the 1 -2000th part of a grain, is, however, necessary. . Compared 
with the method of Marsh, for the purpose of revealing the presence of anti- 
mony, Reinsch's method is twenty times more delicate. 

In this paper Dr. Taylor calls attention to the fact that there is no kind of 
copper available for use in Reinsch's test, that is free from arsenic. The pre- 
sence and influence of this impurity in a medico-legal analysis may be of the 
highest importance, and the facts which have been ascertained by Dr. Taylor, 
and which he has published in this communication, are such as should be known 
to all who may be called upon to make such an analysis. 

The plan which Dr. Taylor recommends for the separation and detection of 
arsenic in liquids and solids, whether organic or inorganic, is based, 1st, on the 
ready conversion of arsenic into chloride; 2d, the transformation of this com- 
pound to hydride by Marsh's process ; 3d, the production of metallic arsenic, 
of arsenious and arsenic acid from the hydride; and 4th, testing the products. 

The whole of this communication is certainly of the highest importance in a 
medico-legal point of view. 

VII. Additional Notes on Diabetic Cataract. By John F. France. 

This communication is made for the purpose of giving a concise resume of all 
that is known and that has been hitherto published upon the connection between 
diabetes and cataract, to which Mr. France was the first to call particular atten- 
tion in the Ophthalmic Hospital Reports for January, 1859. All the examples 
he has collected, twenty-one in number, rest on the authority of living English 
authors. 

The description he gives of the characters displayed by diabetic cataract is 
as follows : — 

"The cataracts have in every example been symmetrically developed on both 
sides ; the lenses have increased remarkably in their antero-posterior diameter, 
so as to encroach upon the depth of the anterior chamber, and even to interfere 
mechanically with the free play of the iris. The opacity has attacked portions 
of the several strata of the crystalline at once, leaving intermediate spaces for 
a while transparent. The colour and bulk of the cataracts have invariably indi- 
cated their soft consistence, which was proved by operation in two persons, 
though respectively of 'middle' and of forty-eight years of age. Lastly, the 
ocular affection has only arisen after considerable duration of the renal malady 
(a circumstance which may tend in some degree to account for the comparative 
rarity of their union) ; and there has, in no case, been reason to suspect further 
disease of the eyeball." 

From the novelty, as well as the importance of the subject, we would call 
attention to the fact that Desmarres, in the work we have already cited, vol. iii. 
p. 522, has an article upon defective vision caused by diabetes. All diabetic 



1861.] 



Guy's Hospital Reports. 



239 



patients, he says, complain of weakness of sight; they become very near-sighted, 
and some are troubled with muscce volitantes. He gives the ophthalmoscopic 
appearances in two cases, which we will relate, as Mr. France states there was 
in no case of diabetes reason to suspect farther disease of the eye. In these 
cases Desmarres found very marked disturbance in the vitreous humour; ecchy- 
moses in the retina, some recent, others old and having undergone absorption ; 
and disturbance in the secretion of the pigmentum, forming what has been called 
maceration of the pigmentum. 

At the conclusion of this communication mention is made of the facts disco- 
vered by Dr. Mitchell in regard to the influence of sugar in causing the develop- 
ment of lenticular cataract, published in this Journal for January, 1860. 

VIII. Remarks on tivo Cases of Extra- Uterine Foetation. By J. Braxton 
Hicks, M. D. 

This communication gives a complete history of two cases of extra-uterine 
foetation, one tubal, the other synthetical, presenting some points of pathological 
and physiological interest. In both cases the parts were examined immediately 
after removal from the body, before they had been immersed in spirit, which 
interferes with correct microscopical examination. 

It is a vexed question whether the decidua-like membrane, found in nearly 
every instance lining the uterus in these abnormal conceptions, is really the 
decidua; and whether the decidua-like membrane surrounding the ovum in its 
new cell, in some cases, is a true decidua; and if so, a production of the ovum. 
On the occasion of a paper contributed by Dr. Robert Lee to the Medico-Chi- 
rurgical Transactions, vol. xli., in the abstract given in this Journal for July, 
1859, we gave our reasons for believing that the results of Dr. Lee's examinations 
were by no means satisfactory, and that more favourable specimens would show 
that, contrary to his doctrine, no true decidua was formed around the ovum 
outside of the uterine cavity. In the cases reported in the present paper, the 
opportunities for making minute examination were most favourable, and the 
conclusions arrived at were that there was no trace of a decidua, or anything 
like it in function or appearance, on the termination of the villi of the chorion. 

It should be added that within the uterus a decidua-like membrane was found 
lining the cavity, in microscopical structure and in vascularity essentially the 
same as true decidua. 

This communication is illustrated by two lithographic plates, containing nu- 
merous figures. 

IX. On Rupture of the Popliteal Artery and Popliteal Aneurism. By Al- 
fred Poland. 

The communication is one of very considerable length, extending over one 
hundred and sixteen pages. It contains cases collected from all sources of rup- 
ture of the popliteal artery, or of an aneurismal sac in connection with the pop- 
liteal artery, without any lesion of the integument. There are 9 cases of com- 
plete rupture of the artery, 19 of incomplete, and 42 of ruptured popliteal 
aneurism, in all 70 cases. The history of each case is given in detail, and in 
introducing the cases of other surgeons, as recorded in the public journals, the 
remarks accompanying each are appended. We can do no more than give a 
brief resume of the treatment adopted, and of the results obtained in these cases. 

Of 6 cases in which no operation was performed 2 recovered, one after 
spontaneous amputation below the knee, and 4 died. 

Of 4 cases in which compression was employed, 2 died from the bursting of 
the tumour externally, and 2 recovered. It must be added, that in a large 
number of cases compression was had recourse to for several days, but had to 
be abandoned as ineffectual, the swelling continuing to increase. 

Of 6 cases in which the popliteal space was laid open by incision, and liga- 
tures placed above and below the rupture, 3 died, and 3 recovered, one of them 
after amputation from failure of the previous operation to secure the lacerated 
artery. 

In 27 cases ligature of the femoral artery was employed. Of these, 16 re- 
covered ; but in 6 amputation was had recourse to ; 11 died, 9 after gangrene, 
and 2 after amputation. 



240 



Bibliographical Notices. 



[July 



In 38 cases amputation was resorted to. In 12 cases the amputation was 
primary; of these, 7 recovered and 5 died. In 26 the amputation was secon- 
dary ; of these, 14 recovered, 10 died, and in 2 cases the final result is not stated. 

X. On the Transference of Poisons from the Blood to the Alimentary Canal. 
By Alfred S. Taylor, M. D. 

It has long been a recognized fact that poisons received into the stomach and 
intestines find their way by absorption into the blood, and are thence either 
temporarily transferred to the solid organs, or eliminated by the various excre- 
tions. 

From the experiments made by Dr. Taylor and Dr. Pavy, recorded in this 
paper, it appears that after injecting arsenic and antimony into the jugular 
vein of dogs, they can afterwards be detected in the stomach and bowels and 
their contents. 

The facts here established may be of some importance in cases where reliance 
is placed on the presence of mere traces of either of these poisons in the 
stomach and bowels, as furnishing evidence of recent administration by the 
ordinary channels. 

XI. Misplacement and Motility of the Kidneys, in reference to the Diagnosis 
of Abdominal Tumours. By Arthur E. Durham. 

The chief value of this communication seems to consist in its offering a quite 
extensive collection of cases in which the kidneys were either misplaced or 
movable in the abdominal cavity. The possibility of a change in the position 
of these organs should be borne in mind in making the diagnosis of certain 
tumours of the abdomen. A laughable circumstance has impressed this Fact 
upon our own mind, and it may be worthy of narration. M. Piorry supposes 
himself able by means of his plessimeter to recognize the exact size of the in- 
ternal organs, and is in the habit of marking out their size, thus recognized, on 
the skin covering them, by means of a crayon of nitrate of silver. On one occa- 
sion, we recollect the opening of a dead body in the dead-house of La Charite, 
on whose back two huge kidneys were sketched in their proper position, when 
the abdominal cavity contained only one, and that was down in the pelvis. 

XII. On Hermaphroditism, as illustrated (principally) by Specimens -in the 
Museum of Guy's Hospital. By Arthur E. Durham. 

In this communication, after declaring his intention of describing, in a series 
of papers in the Reports, the examples of congenital malformations and mon- 
strosities in the Museum of Guy's Hospital, Mr. Durham describes seven cases 
of hermaphroditism. As the study of such cases affords important aid in the 
determination of the mutual homological relations which exist between the 
male and female organs, we will give the view which is most in accordance with 
the cases he records : — 

Ovaries, ...... = Testes. 

Round ligaments, . = Yasa deferentia not pervious. 

Fallopian tubes, = Yesicula? seminales. 

Sinus pocularis and openings into it of 1 

the common seminal ducts, in so far as 1= Vagina and cavity of uterus. 

they belong to the vesiculas seminales, J 

Clitoris, = Penis. 

Nymphas, = Prepuce. 

Labia majora, = Scrotum. 

This communication is illustrated by one wood-cut and a lithographic plate 
containing two figures. 

XIII. An Account of Guy's Hospital Well. By \Villiam Odlixg, M. B. 
This paper gives an account of a well, 2974 feet in depth, which was sunk at 

Guy's Hospital, in 1858, for the purpose of obtaining a supply of water suffi- 
cient for the entire wants of the institution. A plate representing a section of 
the well is appended, showing at a glance the nature of the different strata 
which were encountered. 



1861.] 



Guy's Hospital Reports. 



241 



XIV. Contributions to the Practical Surgery of New Growths or Tumours. 
Series III. Cysts [continued). By John Birkett. 

In this communication Mr. Birkett gives an account of a large number of 
cysts in the neck, of cysts on the spermatic cord, of entozoa-cysts found in vari- 
ous parts of the body; and of cysts developed around foreign bodies. 

Among these cases are several which are peculiarly interesting, in which 
hydatid cysts were developed between the bladder and urethra and the rectum, 
giving rise to retention and suppression of urine, and thus finally destroying life. 
The correct diagnosis of such an affection would be much more difficult than its 
treatment, and the fact of its existence having been established by the observa- 
tion of four cases should be borne in mind. A plate is appended to this paper 
representing a sero-cyst in a child, that extended above and below the clavicle. 

XV. On Poisoning by White Precipitate, by Alfred S. Taylor; with the 
Physiological Effects of this Substance on Animals. By F. W. Pavy. 

This paper is a very interesting one in a medico-legal point of view, for white 
precipitate is not generally described as a poison by toxicologists and chemists. 
By Orfila and Beck, it is passed over altogether, and Dr. Christison merely 
states that it may probably act as an irritant, but records no instance of this 
action. Dr. Taylor details the facts of a recent case of poisoning by this com- 
pound, where a child three months of age died with violent purging and vomit- 
ing, forty-three hours after its administration. 

In the experiments made by Dr. Pavy on animals, the action of white precipi- 
tate was that of a powerfully and purely irritant poison. It proved fatal to the 
dog. rabbit, and mouse, on which animals its effects were tried. The symptoms, 
of course, differed widely in the dog and in the rabbit, on account of the one 
being an animal that is most susceptible of vomiting, the other an animal that 
never vomits. In the dog, the stomach after death was found strewed over with 
patches of ulceration ; the rest of the intestine was almost natural, the stomach 
being probably the only organ on which the poison could act, from its being re- 
jected by vomiting before passing further down. In the rabbit the caecum and 
large intestine were also ulcerated, and the kidneys were affected, being very 
large, and having many of the tubules filled with a whitish deposit, composed 
principally of the phosphate of lime. The results of these experiments proved : — 

1st. That white precipitate, like other insoluble mineral poisons, is absorbed, 
and its mercury is deposited in the organs. It is probably rendered soluble by 
the acid secretions of the stomach. 

2d. That the kidneys are the chief receptacle of the poison, the liver contain- 
ing a trace, and the heart none. The intestines appear to retain the poison only 
in small quantity. 

3d. That whether the quantity administered be large or small, and whether 
given in one or several doses, the quantity found in the body of the animal was, 
in each case, very small. 

• A lithographic plate containing a number of figures is added to the paper, 
for the purpose of showing the effect of the administration of white precipitate, 
in repeated doses, on the kidney of the rabbit. 

XVI. Case of Ovarian Tumour containing Teeth, Hair, etc., with Remarks. 
By S. James A. Salter, M. B., F. L. S., etc. 

The ovarian tumour, the subject of this communication, was found in the body 
of a married woman 49 years of age, the mother of several children. It was 
about the size of an orange ; when opened a quantity of serous fluid, large white 
masses of fat, and bundles of hair escaped. The interior contained three teeth 
implanted in a mass of bone, and a small dark-coloured projecting surface from 
which some fine, pale-brown hair sprouted. All the tissues were subjected to 
careful microscopical examination. 

Sections of the teeth, both vertical and transverse, of all three tissues, enamel, 
dentine, and crusta-petrosa, presented every normal appearance ; it was utterly 
impossible, from structural examination, to discover any difference between these 
and ordinary human teeth. The most interesting result of this investigation, 
however, was the discovery of nerves in the tooth-pulp. In an account of a dis- 
section of an ovarian cyst, by Mr. Gray, in the Medico- Chirargical Transac- 
No. LXXXIIL— July 1861. 16 



242 



Bibliographical jSTotices. 



[July 



tions, vol. xxxvi. (1853), he describes a quantity of nervous matter composed of 
a very large number of varicose nerve-tubules of varying size, intermingled with 
the elementary components of gray matter, viz., nuclei and nucleated vesicles 
containing granules, and states that nervous matter, as far as he has been able 
to ascertain, has never been previously found as forming a part of the contents 
of these cysts. This case of Mr. Salter's is the first, we believe, in which nerves 
normally distributed among other tissues have yet been described. 

The different structures that have been found, from time to time, by different 
anatomists, in these ovarian developments, as enumerated by Mr. Salter, are, a 
nervous centre, distributed nerves, bloodvessels, bone, periosteum, dentine, 
crusta petrosa, enamel, tooth-pulp, unstriped muscle, striped muscle(?), areolar 
tissue, adipose tissue, epithelium, epidermis, sweat ducts, sebaceous follicles, 
and foetal hair. Such an aggregation of structures represents a fresh individual 
of a succeeding generation, though the anatomical form of that individual is 
not normal. 

What calls forth these curious ovarian developments, and whether they are 
the result of conception as it occurs normally in the human subject, are ques- 
tions that have been much discussed. That they are not the result of concep- 
tion seems to us to be certainly established by their having been found in the 
bodies of persons of whose maiden purity and of whose physical virginity there 
could be no doubt, and also by their having been found in the bodies of persons 
so young that gamogenesis was a physiological impossibility. The question as 
to what calls forth these ovarian developments appears to receive its answer in 
the analogy which these formations have to the non-sexual reproduction which 
is now known to prevail in many of the lower animals. 

Until Bonnet, about a century ago, first established the fact that certain 
insects, Aphides, may multiply without sexual intercourse, the doctrine was 
universally held that animal life could alone be propagated by the conjugation 
of the sexes. Since then instances of independent female fertility have become 
so well established and so numerous that the whole aspect of the physiology of 
reproduction has been changed. In a late volume of the Transactions of the 
Linncean Society, in an article on the organic reproduction and morphology of 
aphis, Professor Huxley says : " Time was when the difficulty of the physiologist 
lay in understanding reproduction without the sexual process. At the present 
day, it seems to me that the problem is reversed, and that the question before 
us is, Why is sexual union necessary?" 

Two plates, containing a number of figures, representing the situation of the 
cyst, the teeth, and the appearances of certain of its contents under the micro- 
scope, accompany this communication. W. F. A. 



Art. XXII. — Gours Theorique et Clinique de Pathologie Interne et de Th6ra- 
pie Medicate, par E. Gintrac, Professor de Clinique Interne et Directeur de 
l'Ecole de Medecine de Bordeaux, Membre de la Commission Administrative 
des Hospices Civils, etc. etc. Tomes 4e et 5e, 8vo. pp. 750, 821. Paris, 1859. 

A Theoretical and Clinical Course of Internal Pathology and Medical Thera- 
peutics. By E. Gintrac, Professor of Internal Clinic, Director of the School 
of Medecine of Bordeaux, Member of the Administrative Commission of the 
Civil Hospitals, etc. etc. Yols. IY. and Y. 

M. Gintrac ascribes the very great delay which has occurred in the appear- 
ance of the fourth and fifth volumes of his great work on theoretical and clinical 
medicine, to occupation of his time in the fulfilment of the important duties 
devolving on him as one of the commission having charge of the administration 
of the civil hospitals. The first three volumes received a notice at our hands 
soon after their publication. They displayed throughout, very clearly, the en- 
tire competency of the author for the task he had undertaken, and his perfect 
fairness in its execution. Their character was such as to render us anxious for 
the completion of what had been so ably begun. 



1861.] 



Gintrac, Pathology and Medical Therapeutics. 



243 



In the two volumes before us we find displayed the same industry and judg- 
ment in the selection of materials to serve for the history of the several maladies 
treated of ; for the elucidation of their causes, characters, march and termina- 
tions, and for the exposition of those plans of treatment which are best adapted 
to conduct them to a favourable termination. The facts he has presented are 
collected from every reliable source, and arranged in a manner the best adapted 
to exhibit with clearness the results to which they would seem legitimately to 
lead. No attempt has been made to systematize beyond what carefully con- 
ducted and well authenticated observations fully warrant ; nor has any effort 
been exhibited to gain a reputation for originality by the construction of novel 
theories of disease or new plans for its treatment. In the discussion of every 
question which presents itself in connection with the subjects with which he 
treats, M. Gintrac exhibits a closer adherence to the facts he has to deal with, 
a less inclination to divert them from their most simple and apparent meaning 
than most of the medical writers of his country and times. 

The volumes under review are occupied with that portion of the author's 
course which comprises the pathology and therapeutics of the diseases of the 
skin; namely, 1st. The eruptive fevers and acute exanthemata generally; and 
2dly. The chronic cutaneous affections. Each of these divisions of skin diseases 
is preceded by a series of general propositions, regarding the leading peculiari- 
ties to be observed in the etiology, local characteristics, concomitant pathological 
conditions, march, and terminations, etc. etc., of the several classes of disease 
embraced in it. 

It will not be expected that we should present either a critical notice, or a 
general analysis of the different sections included in either of the volumes before 
us. The task would be most certainly an agreeable and by no means a profit- 
less one ; but the fulness with which M. Gintrac has treated on all the more 
prominent subjects — the account presented of each disease falling, in most in- 
stances, little short of a complete monograph — would require for the fulfilment 
of the task space far beyond what would be proper for us to occupy. All we 
propose to do is to notice such portions of the work as appear to us to present 
points of particular interest, with a recommendation of the entire treatise to the 
careful study of all who would desire to make themselves intimately acquainted 
with the actual condition of our knowledge of the pathology and therapeutics 
of the leading cutaneous diseases which occur in the daily rounds of practice. 
From no source can there be obtained fuller and more reliable information, and 
of a more directly practical application. 

The first three hundred pages of volume fourth of M. Gintrac's course are 
occupied with the consideration of variola, varioloid, varicella, and vaccina. 
The latter subject, in all its important bearings, is treated with the greatest 
fulness and ability. 

The author assumes it as a fact, established by the most incontestable and 
•conclusive evidence, that vaccination is capable of affording to a certain num- 
ber of those who have been submitted to its influence, absolute and permanent 
protection against the occurrence of smallpox ; to others a protection which 
continues but for a definite period, and to others, again, only a partial protec- 
tion ; though even in these latter, should an attack of variola subsequently 
ensue, the previous vaccine infection will be found to exert an influence over 
the latter sufficient to cause it to be less severe, of shorter duration, and far 
less destructive of life. 

A series of general conclusions drawn from the best authenticated observa- 
tions upon record, are presented by M. Gintrac, to exhibit the extent to which 
the variolous and vaccine infections reciprocally influence each other when they 
coincide in the same individual. These conclusions are — 

1st. That, in numerous instances, where the joint occurrence of smallpox 
and the vaccine disease has happened in the same individual, no evidence has 
been presented of any direct influence being exerted by the one disease upon 
the other. Both have proceeded regularly through their respective courses, and 
with their ordinary degree of intensity. 

2d. That, notwithstanding, it is a well established fact that the infection of 
smallpox concurring with that of the vaccine disease, may exercise a marked 



244 



Bibliographical Notices. 



[July 



influence upon the latter. The vaccine infection may be entirely extinguished, 
or it may be retarded in its development until the sixth, seventh, eighth, ninth, 
or tenth day; or it maybe retarded in the several periods of its course, or 
arrested entirely for a period, at one or other of its stages, subsequently, how- 
ever, resuming its course and proceeding on regularly to its termination. The 
vaccine pock, also, may be essentially modified, its areola being very much 
diminished or entirely wanting ; or the subjacent induration and tumefaction 
may be diminished or absent ; or the usual tension of the raised circumference 
of the matured vesicle may be absent, while, in other cases, a suppuration simi- 
lar to that. observed in the pock of discrete smallpox takes place. 

3d. That, on the other hand, the vaccine infection may modify that of the 
smallpox, when the two occur simultaneously. The modifying influence ap- 
pearing to be the most decided in proportion as the vaccine disease has arrived 
the nearest to its termination. Thus : 1st. The inoculation of smallpox per- 
formed on the ninth or eleventh day subsequent to a successful vaccination 
always fails. Performed on the fourth, fifth, or seventh days, it is some- 
times followed by an eruption which Mongenet has shown to consist of small, 
hard, horny prominences, without fluid contents and desiccating by the 
seventh, but sometimes as late as the fifteenth day. 2d. According to the 
observations of James Bryce, the inoculation of vaccinated individuals with 
smallpox matter will give rise to an eruption of vesicles, which in their form, 
and the character of the fluid they contain, have a very close analogy to those 
of the vaccine disease. 3d. Numerous observers have attested to the benignity 
of the smallpox which occurs conjointly with the vaccine disease in the same 
individual. It is, in their estimation, simply a varioloid affection — while, in the 
same house or neighbourhood, the smallpox may prevail, presenting in the 
unprotected a very intense or even confluent form. 4th. The smallpox has 
been known to commence with violent fever and other symptoms of a threaten- 
ing character, and the attack to become, afterwards, so soon as the vaccine 
disease has been developed in the patient, perfectly mild and run a favourable 
course. 5th. In the vaccinated, when smallpox occurs it is either unattended 
with secondary fever, with swelling of the face or with ptyalism, or these symp- 
toms, if they do occur, are very slight. 6th. The duration of the attack of 
smallpox is reduced to twelve, eight, six, five, or even four days. 

The foregoing facts, besides evincing the protective powers of vaccination, 
under ordinary circumstances, show, also, the vast importance of its being prac- 
tised generally, whenever smallpox appears as an epidemic amid any community 
— even in individuals who have been already fully exposed to the contagion of 
the disease. Numerous facts are on record showing that even when vaccina- 
tion has been practised in an individual in whom the variolous eruption has 
already made its appearance, it has in many cases exerted an important modi- 
fying influence, diminishing the virulence, and shortening the duration of the 
disease. 

The question as to the true character of varicella has been very frequently 
discussed, and is still very far from being definitely settled. There are some who 
still insist that it is merely a modified form of variola — a true varioloid affection 
occurring independently of the modifying influence of vaccination — while there 
are others, and perhaps these constitute the greater number, who insist that it 
is an independent, specific, eruptive disease. 

After a careful examination of the facts that have been observed, bearing di- 
rectly upon the subject, M. Gintrac has arrived at the following conclusions, 
namely : — 

" 1st. The varicella may prevail under the same circumstances as the small- 
pox, and appear often in such a manner as would seem to indicate that it owed 
its origin in some manner to the latter disease. 

"2d. It has been supposed that varicella is capable of giving rise to smallpox, 
but there are serious doubts as to the correctness of such an opinion. 

" 3d. Varicella and smallpox are entirely distinct diseases, comporting them- 
selves towards each other and in respect to the vaccine infection in a manner 
altogether distinct the one from the other. 

" 4th. Notwithstanding their apparent analogies smallpox and the varioloid 



1861.] 



Gintrac, Pathology and Medical Therapeutics. 



245 



disease, on the one hand, and varicella on the other, are distinguishable from each 
other by the difference in the poison by which they are respectively produced, 
by their essential characteristics, and their special affinities, as well as by their 
anatomical characters, and the peculiarities of their respective eruptions." 

It is certainly a very curious circumstance that, if varicella be a disease so 
entirely distinct from smallpox as it is supposed to be, it should ordinarily make 
its appearance during the epidemic prevalence of the latter ; or should succeed 
it, and conform itself to its particular movement after a short interval, in the 
same locality. 

M. Gintrac, at the Internal Clinic, has known the smallpox, varioloid, and 
varicella to coincide, presenting an exact relation to each other, in respect to 
the number of cases of each disease, year after year, as seen by the annexed 
table. This we think of sufficient interest to warrant our inserting it entire : — 



In 1839 thei 


•e were 26 cases of smallpox, 15 of varioloid, 


and 13 of varicella. 


" 1840 " 


" 18 " " 21 


" 6 


a 


" 1841 " 


" 10 


4 


" 2 




" 1842 " 


u 5 


« 2 " 


" 3 


a 


" 1843 " 




1 


" 3 




" 1844 " 


" 22 




" 25 


a 


" 1845 " 


" 5 


3 


" 6 


a 


" 1846 " 


" 13 


6 


ci 7 


u 


" 1847 " 


" 25 


•f.^' 14 


" 13 




" 1848 " 


« 15 


6 


" 8 




" 1849 " 


" 13 


7 


" 9 




" 1850 " 


" 5 


6 


" 3 




" 1851 " 


" 5 


3 


" 8 


a 


" 1852 " 


" 16 


15 


" 31 




" 1853 " 


« 9 


n 9 u 


" 7 


it 


" 1854 " 


" 32 


38 


" 13 




" 1855 " 


" 16 


14 


7 




" 1856 " 


" 7 


14 


" 9 






243 


192 


173 





The next subject discussed is scarlatina, its etiology, pathology, and treat- 
ment. To this, one hundred pages of the volume are devoted. The account 
given of the disease is very complete and satisfactory. The leading facts known 
in relation to it have been collected with surprising industry and arranged with 
judgment. The author's deductions from them, aided by his personal experience, 
are, in general, cautious and truthful. 

After disposing of scarlatina, M. Gintrac next takes up the subject of measles; 
in connection with which he treats of two other eruptive maladies which are 
supposed to have more or less affinity with it, if not in their actual pathological 
nature, in, at least, their leading phenomena. Both these latter diseases have 
been repeatedly observed by our own physicians. Their true nature and rela- 
tions are, however, but little understood. 

Rougeola, morbilli, and rubeola are given by most writers as synonyms of one 
and the same disease, that, namely, known to us under the name of measles. By 
the French writers, generally, the term rougeola is employed to designate 
measles, while Sauvages employed indifferently the terms morbilli and rubeola. 
By the German physicians, however, the last-mentioned term is applied to an 
eruptive affection entirely distinct from measles, while Willan and Bateman 
apply it exclusively to the latter affection. In consequence of this want of uni- 
formity among medical writers in the use of the terms referred to, not a little 
confusion has crept into the nomenclature of measles and certain allied exan- 
thems. M. Gintrac would have the term morbilli used to designate measles — 
the rougeola of the French. This disease to be always spoken of as the mor- 
billous exanthem, and not as rubeolous. 

There are then, we may remark, three distinct diseases : morbilli, rubeola, and 
roseola ; all of which have apparently a close relationship. 

Morbilli, or measles, is an acute, febrile, contagious exanthem, marked, 1st. 



246 



Bibliographical Notices. 



[July 



By red, distinct patches, small in size, irregular in form, and disseminated over 
nearly the entire surface of the body ; 2d. By an irritation more or less acute, 
and a catarrhal condition of the mucous membrane of the eye, nose, and laryngo- 
bronchial tube. 

Rubeola, according to the German medical authorities, is a hybrid disease, 
presenting a combination of the symptoms of both scarlatina and measles. It 
is not a simple combination of the two, where each of the diseases maintains 
throughout its individuality, the one succeeding the other without being con- 
founded with it, but an actual fusion of the two. If the characteristics of the 
one seem to predominate, they are nevertheless not the less evidently under the 
control of the other. 

The phenomena which occur in the mucous tissue indicate the coexistence 
and co-operation of the two morbific elements, and the phenomena of which the 
skin is the seat, prove their reciprocal modifying influence. The eruption being 
not exactly that appertaining properly to either of the two diseases which are 
present. 

" In admitting that rubeola is a kind of mixed disease, or hybrid, which is 
equally distinct from scarlatina and measles, having a special being and special 
attributes, we may conclude from a collation of all the facts in our possession. 

" 1st. That it is sometimes sporadic, and may also appear under an epidemic 
influence. 

" 2d. That under certain circumstances, it has appeared to be the result of the 
occurrence simultaneously in the same individual, of the morbillous and scarla- 
tinal infections. 

"3d. That although itself the result of contagion, it is, nevertheless, not pro- 
pagated by contagion. 

"4th. That it never attacks the same individual a second time. 

" 5th. That the previous occurrence of scarlatina or measles is no protection 
against an attack of rubeola. 

" 6th. That it has been observed in infants, and young subjects generally, oc- 
casionally in adults, but very rarely in those of advanced age. 

" 7th. That its onset may resemble that of scarlatina or that of measles, but very 
soon the symptoms of [both diseases become united, so that on the one hand we 
have ocular irritation, coryza, laryngitis, and bronchitis, and on the other, 
angina, redness of tongue, tumefaction of parotids, otitis, etc. 

" 8th. That the eruption, which makes its appearance from the third to the 
sixth day, and sometimes sooner, spreads very rapidly over the entire body, but 
sparing often the face. It presents itself under the appearance of large angular 
distinct patches, often confluent, and of a more or less bright hue. 

" 9th. That the patches are often beset with vesicles ; sometimes they present 
irregularities, and varied aspects, in different subjects and on different portions 
of the surface ; and are very generally followed by a very decided furfuraceous 
and lamellar desquamation of the cuticle. 

" 10th. That, in general, rubeola has a duration of from five to ten days. 

" 11th. That while it has ordinarily a character of some severity, its termina- 
tion is more frequently favourable than otherwise. 

" 12th. That its most common sequela are abscesses of the neck or dropsical 
effusions, especially anasarca." 

Roseola is an exanthem of red patches scattered over the surface of the body ; 
it is preceded by fever, but is unattended with any special affection of the 
mucous tissues. In its acute form it is liable occasionally to be confounded with 
scarlatina or measles. 

When the patches of roseola are large and approach each other closely, 
Gregory has known it to be taken for an attack of scarlet fever ; more especially 
is this liable to occur when, as often happens in severe cases, there is some red- 
ness of the pharynx. The error of diagnosis, in even those cases in which the 
semblance to scarlatina is the strongest, will be speedily rectified. The intensity 
of roseola seldom bears any comparison with that of scarlet fever. The patches 
in the first always remain distinct, while they quickly coalesce in the second. The 
slight redness of the pharynx which is met with in cases of roseola, bears no 
comparison with the intense angina observed in scarlatina. 



1861.] 



Gintrac, Pathology and Medical Therapeutics. 



24? 



There is, confessedly, a much closer resemblance between roseola and measles 
than between it and scarlet fever. The patches in measles are, however, smaller 
and more regular in shape. But if our diagnosis be predicated solely on the 
character of the eruption it will be found somewhat difficult to distinguish 
between the two diseases. There is reason to believe that many of the cases of 
reputed recurrence of measles have been nothing more than attacks of roseola 
succeeding to an attack of the former disease. The most certain diagnosis is 
based upon the march and duration of the two maladies. The measles runs 
through its several periods more slowly than roseola, and the eruption is less 
prompt in its appearance. It is a disease, besides, of greater severity. In 
roseola there is an absence of those symptoms which denote a fluxion to the 
mucous tissue of the eyes, nose, and bronchi ; there is also a liability to a 
recurrence of the disease ; it is, finally, not capable of being propagated by con- 
tagion. 

Among the remaining subjects treated of in the fourth volume is a very 
complete exposition of the history, pathology, and treatment of purpura, epi- 
demic miliary fever, and the several forms of pemphigus ; drawn up with much 
ability, and conveying clear ideas of the character, phenomena, and march of 
these affections, with a satisfactory resume, of the results of clinical experience 
as to their proper treatment. 

The first of the diseases treated of in the fifth volume is erysipelas ; in re- 
gard to which M. Gintrac presents a very fair digest of the leading facts upon 
record; he has not, however, drawn from these facts what in our estimation 
are the legitimate deductions to which they lead. In that form, at least, of 
erysipelas which is liable to prevail epidemically, and which in many portions 
of the United States has extended over large districts of country, and at times 
caused no inconsiderable amount of mortality, we certainly have something 
more than merely a specific inflammation of the skin, even though this inflam- 
mation be referred to some general modification of the organism. The facts 
that have been collected of late years in regard to the etiology and pathology 
of the disease have led us to consider it as a true zymosis; in many cases 
presenting no affection whatever of the surface, but instead of it an intense, 
often very acute inflammation of the mucous tissues — particularly of the fauces 
and respiratory organs, or of the serous tissue of the abdomen — the peritoneum. 

Following the account of erysipelas is a very excellent one of sclerema or 
induration of the subcutaneous cellular tissue of infants. 

After adducing a synopsis of the facts that have been recorded in reference 
to the history, causes, symptoms, varieties, complications, duration, and termi- 
nations of this curious and but little understood affection, M. Gintrac presents 
the following as the general conclusions to be drawn from these in regard to its 
true pathological character. 

Sclerema is not the result of syphilis as Doublet supposes, nor of pneumonia 
as Hulme believes, nor of gastro-enteritis, nor of a lesion of the liver, and a mor- 
bid state of its secretion causing an augmented plasticity of the fluids ; it does 
not result from a non-occlusion of the foramen of Botalus, nor is it the result of a 
progressive asphyxia of the new-born infant. This is evident from the fact that 
syphilis is only a very rare coincidence — that the lungs are often healthy, and 
when not so rather congested than inflamed — that the stomach and intestines 
are often in a normal condition. Jaundice when it occurs is a simple complica- 
tion, while lesions of the liver are of rare occurrence or of little importance. 
The foramen of Botalus and the arterial canal are often found more or less 
completely obliterated ; in fine, the infants attacked with sclerema have really 
respired, and their lungs have become fully dilated at the moment of birth, and 
if asphyxia occurs it is rather the effect than the cause of the disease. 

Let us consider, says M. Gintrac, the circumstances under which acute scle- 
rema is produced. A being, who had lived a borrowed life, protected on all 
sides from external influences, is suddenly abandoned to itself and surrounded 
by new agents which produce a painful impression upon its organs. It is par- 
ticularly feeble, and if the impressions to which it is. subjected are intense and 
prolonged, morbid effects will necessarily occur, in consequence of the difficulty 
with which it resists the difference in the circumstances amid which it is so 



248 



Bibliographical Notices. 



[July 



suddenly placed. M. Hervieux has carefully studied the influence direct of 
these causes in the production of the progressive algidity of the new-born infant. 
The gradual slackening- of the circulation and respiration ; the lowering, more 
and more evident, of the heat of the body ; the gradual extinction of the life of 
the infant, constitute the distinctive characters of that condition, which, though 
not sclerema, is frequently one of its elements. The occurrence of sclerema 
M. Gintrac supposes to be consequent on an attempt at reaction. The afflux 
towards the periphery, the injection of the cutaneous capillaries, the tumefaction 
and hardening of the subcutaneous tissue indicate an organic effort, a conges- 
tion, and, when erysipelas complicates the sclerema, even a special inflammatory 
action. 

Sclerema is, therefore, according to our author, a complex affection, while the 
progressive algidity is a more simple morbid condition, a more directly physical 
result of exterior influences. Congenital sclerema is not due, of course, in any 
degree to these influences. It shows, on the contrary, the evidence of an afflux 
of fluids and a primitive engorgement of the tissues. This congestive condition 
gives only a very inadequate idea of sclerema. The disease is produced when 
an effort at reaction commences, but is not accomplished — when it exhausts 
itself in useless efforts — when the fluids accumulated in the vessels or extrava- 
sated are, as it were, arrested and coagulated. When the local circulation is 
arrested at the same time the caloricity decreases and the vitality becomes ex- 
tinct. But this defect of reaction renders it presumptive that either the per- 
turbing cause is of some intensity, or that the strength of the organism, already 
exhausted, is insufficient to produce an efficacious effort. In comparing these 
several circumstances, we recognize as elements of sclerema a debility of the 
new-born infant, either primitive or acquired ; a refrigeration either momentary 
or sustained ; congestions of the central organs and of the periphery; inefficient 
attempts at reaction of short duration ; a rapid decrease of calorification, of 
the circulation, of respiration, and of innervation — a gradual abandonment of 
the organism to the general laws which preside over inanimate bodies. 

The treatment of sclerema is by no means well settled. The few observations 
of a truly practical bearing which have been published in respect to the most 
rational therapeutic management of the disease have been collected by M. 
Gintrac ; as we know of no one who has presented so satisfactory a digest of 
these we believe that we shall be performing an acceptable service to our readers 
by presenting that digest entire. 

" To prevent the occurrence of acute sclerema the utmost care should be 
taken to prevent the new-born infant from becoming chilled. If carried from 
place to place it should be warmly clad, and early supplied with good milk. 
"When any indication is presented of the development of the disease our care is 
to be redoubled. The air of the chamber which the infant occupies should be 
kept at a temperature of from 15 to 16 degrees Centigrade — 68° to 70° Fah- 
renheit. The infant from time to time should be placed before but not too near 
a clear fire, its position at the same time being frequently changed. Its head 
should be kept constantly somewhat elevated, all compression of the trunk and 
limbs avoided ; they should be kept free from all restraint, but at the same time 
enveloped in wadding and flannel. Frictions of the surface should be practised 
with a soft warm hand, and at the same time a species of kneading of the parts 
that are engorged, hard, and cold. 

"M. Legroux has presented some very interesting practical remarks upon the 
utility of kneading and muscular excitation in this disease, by which he has been 
able to save a number of infants. The success of this treatment is due in great 
part to the early period at which it is put in practice. There is no reason, how- 
ever, that even after several hours have elapsed since the invasion of the disease 
we should not endeavour to realize, some, at least, of the benefit which M. Le- 
groux claims to have derived from frictions, gentle and methodic pressure upon 
the limbs, and upon the thorax to solicit and render more complete both expira- 
tion and inspiration, and causing the limb to perform the movements of flexion 
and extension, etc. M. Hervieux insists upon the utility of these proceedings, 
but more especially those adapted to remedy the progressive algidity, which is 
the primary element of the disease. We should not forget, at the same time, 
to put the infant very frequently to the breast of a healthy nurse. 



• 



1861.] Routh, Infant Feeding and its Influence on Life. 249 

" Tepid and aromatic baths have been employed ; those of vapour have, 
however, been considered as more efficacious. By Souville the infants were ex- 
posed to the action of the vapour by being placed upon an osier platform, and 
turning them constantly in every direction ; a more ingenious apparatus, how- 
ever, is employed at the Foundling Hospital: The infants there are placed to 
the number of six or twelve, upon a hammock, and this is inclosed in a kind of 
glass stove — here they are left for about twenty minutes. Under the influence 
of the bath the infants experience a sense of comfort, and on coming out of it 
apply themselves more readily to the breast. Valleix is fearful that the vapour 
bath, which can acquire a temperature of even 36 to 40 degrees (110°toll2°Fah.), 
may produce serious congestions. Its proper use requires, certainly, great care 
and no little practice. 

"The state of plethora, the lividness of the surface, and the vascular injection 
detected after death have suggested the detraction of blood. Liberali and 
Palletta have had recourse to leeches to the legs or upon the thorax. The last- 
mentioned writer speaks of them as particularly efficacious ; MM. Leger and 
Yalleix have both seen good results from their use. M. Gintrac tested their 
effects in 1826 at the Foundling Hospital. The first patient upon whose epigas- 
trium a single leech was applied lost a large amount of blood, and sank rapidly. 
In a second case, the utmost watchfulness was observed ; at the end of two 
hours the bleeding having been arrested by the use of a crayon of nitrate of 
silver, the infant was well. The same result was often observed. The applica- 
tion of a single leech seemed to him always to be sufficient. It is in oedematous 
sclerema that this moderate loss of blood is beneficial, especially if indications 
are present of pulmonary or cephalic congestion. When there is pallor of the 
surface, with intense coldness and a very great hardness of the affected parts, in 
a word, when the indications of adipous or concrete sclerema are present, the 
application of even a single leech would be improper. 

" In a similar case Andry and Auvity have had recourse to blisters to the 
thighs ; it would be better, perhaps, to apply them to the chest. 

" Fomentations with a decoction of cinchona have been employed, as, also, 
frictions with camphorated and aromatic liniments, etc., or inunction with the 
mercurial pommade. These topical applications are all inferior in efficacy to 
the kneading process of M. Legroux. Finally, the ipecacuanha has been used 
internally by Horn, a tonic potion by Chaussier. In the more grave cases, how- 
ever, there is a difficulty in swallowing— while in the lighter cases the remedies 
indicated are useless. In both, milk will be found to do more good than either. 
For the new-born infant it is the best of tonics." 

Among the acute eruptive diseases subsequently treated of by M. Gintrac, the 
most prominent are erythema and urticaria : then follows the consideration of 
the chronic cutaneous diseases, including those, also, of the hair, nails, etc. 
The latter department exhibits on the part of M. Gintrac the same patient 
industry in the collection and collation of facts, the same caution in the deduc- 
tions he has drawn from them, and the same ability in the application of these 
for the elucidation of the character of the diseases treated of and their most 
successful management. In the author's account of the different chronic cuta- 
neous affections there is much to interest, and we could very profitably indulge, 
could we afford the space, in many an extract. In conclusion, we would recom- 
mend the work before us as a most valuable addition to the library of every 
practising physician. D. F. C. 



Art. XXIII. — Infant Feeding and its Influence on Life ; or the Causes and 
Prevention of Infant Mortality. By C. H. F. Kouth, M. D., M. K. C. P. E., 
M. R 0. S., Physician to the Samaritan Free Hospital for Women and Chil- 
dren, etc. etc. 12mo. pp. 379. London, 1860. 

The proper feeding of infants is a subject which commends itself to the at- 
tention of all : the physician, the parent, and the philanthropist are all equally 
interested in its study. There are few things, however, in relation to which 



250 



Bibliographical Notices. 



[July 



there exist, in all directions, a greater amount of ignorance, and more mis- 
chievous prejudices. The mistakes daily committed in respect to it are pro- 
ductive of a large amount of suffering and mortality among our infant popula- 
tion. Even when errors in the feeding of infants do not act as a direct cause 
of disease they impair the nutrition of the child's system, reduce its vitality, 
and predispose it thus to the attack of maladies of the most serious character. 

All perhaps are agreed that the only natural and appropriate aliment of the 
infant during the first eight, ten, or twelve months of its existence is the milk 
supplied it from the breast of its mother, or from that of a suitable nurse ; and 
few will deny that it is a duty incumbent on every mother to suckle her babe. 
No one who has carefully examined the subject but will confess that by a ne- 
glect of this maternal office moral and physical evils are nearly always entailed 
upon the parent, and often irremediable injury upon her offspring. Still, there 
certainly do occur instances, more rarely perhaps than has been generally sup- 
posed, in which the infant cannot be nourished at the breast of either its mother 
or of a suitable nurse. Now, under these circumstances, the important ques- 
tion presents itself, what is to be done? where are we to find a proper substitute 
for the natural aliment ? 

The question is taken up and most fully and ably investigated by Dr. R., and 
under circumstances that would seem to be well adapted to insure a good degree 
of accuracy in the conclusions at which he arrives. 

Dr. R. commences by showing, from authentic and varied statistics, the very 
high ratio of mortality which everywhere occurs among infants in foundling 
hospitals. He believes it to be an error, however, to refer this excessive mor- 
tality to the deprivation of breast-milk as its only or principal cause. In the 
several foundling hospitals no common law of mortality is to be observed, not 
even in the same institution during different years, to warrant the conclusion 
that in all of them there is one common morbific cause in operation — and that 
that cause is the absence of breast-milk in the dietary of the inmates. How- 
ever injurious and destructive the latter may be, there are many other morbific 
causes also in co-operation. The several foundling institutions are placed in 
very dissimilar circumstances as to climate, location, cleanliness, and the num- 
ber of their inmates. The quality of food supplied, and the principles upon 
which the children are fed, in these institutions, are so different, that absence of 
breast-milk could only account for a small share of the mortality. It is asserted 
and indeed proved that in Ireland, the mortality among orphans and foundlings 
in the hospitals is less than among the children of the general population out 
of doors. 

From a large number of facts and statistics which have been collected and 
carefully collated by him, Dr. R. arrives at the following general conclusions : — 

"1. That for the ages of one year and under five, the mortality, even under 
ordinary circumstances, is in towns nearly double what it is in the country; but 
this difference in the mortality according to residence is nearly seven times as 
great for foundlings ; therefore, foundlings should never be maintained in towns. 

"2. That in Ireland, while it is doubtless very high in the first month, for 
those under one year it is only 30 per cent, in towns, and 22 per cent, in the 
country ; the worst mortality with foundlings being 50 per cent. 

" 3. That travelling in fair seasons is not dangerous to foundlings. 

"4. That the mortality is greatest in spring, and least in autumn, with children 
in public institutions. 

"5. That a chief cause in the mortality of foundlings is want of exercise, and 
the abuse of the recumbent position. 

" 6. That want of breast-milk will only account for a mortality of 3.4 per cent, 
additional. 

" 7. That a depraved hospital atmosphere and certain endemic contagious 
disorders are the chief causes of the mortality in foundling hospitals."' 

After adducing a series of very striking facts and statistics in illustration of 
the advantages of breast-milk for the food of the infant in insuring its life and 
proper and harmonious development, Dr. R. proceeds to examine the reasons 
that are urged why a mother should not suckle her child, and he shows very 
clearly as the result of such examination how very few are the valid causes 



1861.] 



Routh, Infant Feeding and its Influence on Life. 



251 



that should justify a parent in the abandonment of her maternal duties towards 
her infant. 

The subject next discussed is the proper selection of a wet nurse when one is 
necessary. The importance of good moral character, general intelligence, and 
evenness of temper in the nurse every one will admit ; but the physical qualifica- 
tions the possession of which is essential to enable her to perform her duty 
towards the infant committed to her charge are not so well understood ; they 
are thus enumerated by Dr. E. : 1. She should have good milk, the characteristics 
of which are given. 2. Her hereditary predisposition should be good ; especially 
should she be free from any proclivity to tuberculosis, syphilis, or indeed any 
transmissible malady. 3. Her age should not exceed 30. 4. The period of her 
confinement should not have been many months before or after that of the 
child's mother. 5. She should not be of a melancholic temperament. 6. Her 
milk should not only be good in quality but also sufficient in quantity. 7. When, 
however, an infant cannot be suckled entirely by a wet nurse, artificial feeding 
may be assisted by its being occasionally put to the breast of a married woman 
who is at the time nursing her own infant. 

The immediate morbid results of defective assimilation in infants consequent 
upon the use of improper aliment, in conjunction with the effects of bad air and 
want of cleanliness, are very accurately depicted by Dr. E. He divides the 
morbid condition or atrophy induced under such circumstances, into three 
stages. During the first stage, there may be a semblance of health, the spirits 
of the child being but little affected. More commonly, however, it is at times, 
and apparently without cause, unusually peevish and irritable. Its flesh be- 
comes flabby and the skin loses the silky texture so common in healthy children 
during the first months of existence. The infant will frequently throw up its 
food having an intensely acid smell. Its appetite is impaired and its sleep is dis- 
turbed. The bowels may be constipated ; the stools, when obtained, being clay- 
like with white lumps in them. All these symptoms are increased in intensity 
during the second stage. There is now more decided irritation of the intestinal 
canal ; frequent vomiting and diarrhoea may be present, the stools being very 
green and offensive, and so acid as often to excoriate the fundament and surround- 
ing parts. The emaciation is more rapid, the eye assumes a peculiarly bright 
expression, and the child has an aged look. Sometimes there is no diarrhoea ; 
the stools, however, when they occur being replete with undigested matters. 
Emaciation is always present. A further development of the symptoms enume- 
rated constitutes the third stage. The child's appetite becomes voracious, 
nothing seems to satisfy it. Aphthae appear in the mouth and gradually extend 
down the alimentary canal. There is often an unmanageable diarrhoea : thirty 
to forty motions a day, of little else than undigested food, are not uncommon. 
The emaciation becomes frightful : in the course of a few hours the infant 
acquires the look of a wrinkled old man. There is an unnatural brightness 
of the eyes, which seem to project beyond their sockets. The voracity con- 
tinues to the end. It is sleepless, constantly whining or crying. Emaciation 
constantly goes on until the child dies in the last stage of inanition. 

Dr. E. believes that the aphthous form of the disease, especially when a 
number of children are congregated together in small and unventilated apart- 
ments, is apt to assume a contagious character and become exceedingly malig- 
nant. The disease being communicated by the use of the same towel, spoon, 
or artificial nipple. The aphtha? in these cases are not confined to the mouth 
and alimentary canal, but occur occasionally upon the conjunctiva, upon the 
vulva in girls, etc. 

•When diarrhoea is absent the disease may extend over a period of several 
weeks. It is singular how the little shrivelled, old-looking child will be seen to 
smile at one, particularly after a meal ; a temporary sunbeam appearing as it 
were in the midst of the general wreck. In these protracted cases no quantity 
or kind of food, no form of medicine will do any good, however assiduous and 
varied are the trials made. 

Sometimes after running into the second stage, or it may be even in the first, 
the disease does not follow out the course described — primary assimilation is 
defective only, not entirely arrested. Tuberculosis then makes its appearance, 



252 



Bibliographical Notices. 



[July 



generally as tabes mesenterica, more rarely as phthisis. By far the most 
common of the maladies developed, however, is anaemia with more or less of 

rachitism. 

The post-mortem appearances are, extreme emaciation, little fat remaining ; 
very scanty cellular tissue ; great wasting of the muscles throughout. In cases 
attended with diarrhoea, the entire alimentary canal is lined with red patches 
and aphthae, varying in size from that of a pin's head to that of a bean. Peyer's 
glands are much reddened and swollen. In some cases no aphthae are present, 
but the mucous membrane from below the biliary ducts is much reddened, with 
a bloody intensely acid mucous exudation upon its surface. When there has 
been no diarrhoea the alimentary mucous membrane is pale, but Peyer's glands 
are much swollen, projecting from the mucous membrane in round patches, 
some three or four lines broad by ten or twelve long, apparently filled with 
exudation, and precisely similar to their condition as observed in cases of 
Asiatic cholera. 

The proximate as well as the remote causes of defective assimilation in the 
infant being most intimately associated with bad or defective alimentation 
during the first stage of existence, Dr. R. proceeds to discuss the correct prin- 
ciples of feeding during infancy, laying down at the very outset the two follow- 
ing positions in respect to the management of infants, as essential to their 
preservation : 1st. That the infant, especially during the early periods of its 
existence, should be kept warm, artificially or naturally, during the time it is 
being fed ; 2d. That a child should be made to take at such periods the semi- 
erect position, which is the natural one. 

Dr. R. maintains, and we think very properly, that animal food is indispensable 
during infancy. Food to be capable of supporting life must contain three sub- 
stances in due proportion : 1. Plastic or nitrogenous matter to nourish the 
fleshy parts of the body — fibrin, albumen, or casein ; 2. Calorifiant or combus- 
tible matter, i. e. hydrocarbons, to supply the respiratory process, to keep up 
animal heat, and to provide fat for the body — fats and oils, sugar and starch; 3. 
Mineral matters, or salts, to supply the bones, and hold in chemical union, com- 
bination, and action, the solids and liquids of the body — lime, potash, soda, 
magnesia, in union with phosphoric, sulphuric, hydrochloric acids and many 
others. Milk contains all these elements : Casein, the plastic ingredient ; fat 
and sugar, two combustible substances, and the several needed mineral matters. 
Hence milk if given in sufficient quantity will support life for any length of 
time. The proportions in which these three elements of food are contained in 
other aliments vary ; it should be, at least, 10 of plastic to 30 or 40 combustible, 
while the mineral should vary from 1.5 to 6 or 7 per cent. 

Dr. R. points to the fact that the best and most simple substitute for human 
milk is, clearly, milk from some other animal, especially when this can be taken 
by the infant by suction direct from the nipple of the animal. The milk of 
the ass, goat, and cow, are the substitutes usually resorted to. The milk of the 
ass contains more water than that of the human female ; only about half as 
much butter and casein, but nearly twice as much sugar and salts. Goat's milk 
approaches nearer in composition to woman's milk. The quantity of the milk 
varies somewhat in the different breeds of goats, and, also, according to the 
nature of the food the animal is fed on, and the care bestowed upon its keeping. 
Cow's milk has less water than women's milk, a larger amount of solid matters ; 
more casein, more butter, and more salts, but less sugar. Like that of the goat 
its qualities, also, are modified by the breed, the food, and the care taken of the 
animal ; usually also by the season of the year. It is probable that the milk 
of either the goat or cow, when either animal is healthy, and properly fed and 
cared for, will furnish an aliment well suited for children who are necessarily 
deprived of the mother's breast or that of a good nurse. Dr. R. believes that 
the milk obtained from cows fed upon beet-root, with a very small dilution of 
water, might be brought so closely to resemble human milk as in all respects 
to perform the same services. 

The efforts to rear infants upon the milk of animals will often fail, however 
well to all appearance conducted. The use of such milk often gives rise to the 
generation of a large amount of acid, and not unfrequently to a wasting diar- 



1861.] Route:, Infant Feeding and its Influence on Life. 



253 



rhcea. When this is the case, it is said that a mixture of one pint of cream 
to three of water will often prove very beneficial. Cream contains very nearly 
the same ingredients as milk, except that the casein is diminished, and the fatty 
matters considerably increased. In this manner, Dr. E. remarks, the absence 
of sugar is compensated for by the excess of fatty matters, and the mixture 
becomes sufficiently rich, both as a nutritive and calorifiant aliment, The addi- 
tion of water diminishes the density, and renders the cream more digestible. 
The tendency to acid may be removed, the solubility of the casein and the emul- 
sion of the fatty matters insured, and both rendered more assimilable by the 
addition of half an ounce of lime-water to every half pint of the mixture. 

Desiccated milks have not been used to a sufficient extent to enable us to 
judge positively of their fitness as an aliment during early infancy. Eggs 
approach very nearly to milk in their composition, and may be resorted to with 
propriety as an article of food for infants. The white, however, should be given 
as nearly as possible raw, or only heated to 130° F. Beyond this temperature 
it coagulates, and is then much more difficult of digestion. If the egg be put in 
boiling water for two minutes only, it will have merely a thin layer of albumen 
coagulated on its surface, and at the same time be warmed sufficiently through- 
out. Cow's milk contains 5.5 of casein per cent., the white of eggs as much as 
11.1, the yolk 1.5, together 12.6. Eggs, therefore, should be diluted ; and, with 
a little sugar of milk added, would form a very fair substitute for milk. Beef- 
teas, in whatever way prepared, are rather doubtful forms of aliment in the 
case of infants, while jellies are unassimilable : they only overload the blood 
with nitrogenous products, and thus impair its purity and its adaptedness to 
build up properly the several tissues. 

It has been found that raw meat very finely shred, or scraped into a pulp 
will often be eagerly taken and always perfectly well digested by young chil- 
dren. Its use, however, is not recommended as an ordinary article of food, but 
only in cases of long standing diarrhoea. In many of these cases, apparently, 
it has been to it alone that the preservation of the life of the patient was 
attributable. Dr. R. considers it to be, probably, one of our most important 
remedial means in the treatment of defective assimilation. There is a danger 
attendant upon the use of raw beef as an article of diet unless there is a cer- 
tainty it is in all respects perfectly healthy, and that is the generation by it 
in the human body of certain parasites, among which may be enumerated tape- 
ivorm, the cysticercus, and trichina spiralis. 

In the infant as well as in the adult, variety is essential to the maintenance of 
health. There has long existed a prejudice, both in and out of the profession, 
in favour of vegetable food, particularly farinaceous, during the earlier periods 
of existence. The views upon which this prejudice is based are altogether 
erroneous. Vegetable food is neither easily digested, nor in the proper sense 
of the term, nutritious. To some extent the erroneous views in reference to 
this subject have been corrected by recent more accurate observations. Accord- 
ing to Dr. R., the earliest period at which vegetable food can be borne is about the 
eighth month. "The teeth which appear," he remarks, " are not of value be- 
cause they are then capable of mastication, but simply as evidence that changes 
have occurred in the organs of digestion, which have progressed pari passu, and 
that the salivary and pancreatic glands of the membranous stomach are in full 
development, and capable of digesting vegetable aliment. Then, and only then, 
therefore, as a rule, may vegetable food be given, and consequently weaning may 
be tried, if necessary." But even then only the most easily digestible vegetable 
substances should be allowed at first ; and it is best to continue, also, in a great 
measure, the animal milks in combination. 

In proceeding to consider the treatment of defective assimilation, Dr. R. 
refers again to the facts which prove the superiority of the mother's milk, or 
that of a proper nurse, for the nourishment of the infant, and its influence in the 
preservation of the health of the latter, even when its use is combined with in- 
judicious hand-feeding, showing the importance, therefore, of securing, by every 
effective means, the natural aliment to the infant for as long a period as possible. 
Even in cases in which it is not secreted in sufficient quantity to furnish the 
entire nourishment of the infant, the mother should not be permitted to desist 



254 



Bibliographical Notices. 



[July 



entirely from suckling ; the deficiency of the nourishment supplied by her being 
made up in the mean time by artificial food of a suitable quality, while every- 
thing is done with the view to increase the flow of milk from the maternal 
breast. 

The subject of defective lactation and its treatment is discussed by Dr. R. 
under three heads : 1st. When the defect arises from a state of hyperaeniia from 
over-feeding, etc. ; 2d. When it is attended with a weakened or anaemic state 
of the body ; 3. When it results from torpor of the breast. The first variety 
is the least common and by far the most easily got rid of. The third is the most 
frequent ; it is usually met with in middle-aged females, or those who have 
married at a late period in life, or who are somewhat masculine in form and 
character ; it may result also from paralysis, mental emotions generally, disease 
of the female organs, with or without atrophy of the mamma, excessive obesity, 
impure air, and the neglect of regular lactation. In the first variety the reme- 
dies are a gentle purgative, a more simple, less exciting diet, the entire disuse 
of all fermented or distilled liquors ; at the same time, care being taken that a 
due amount of nutritious matter be taken in order to prevent a complete sus- 
pension of the secretion of milk. The second variety calls for a nutritious diet, 
light stimulants and tonics ; gentle daily exercise and a pure, free air. In many 
of the cases belonging to the third variety the deficient action of the mammary 
glands cannot be restored, in others, however, the supply of milk may be aug- 
mented by artificial suction or drawing of the breasts; by electricity; by a 
proper diet and regimen, certain local applications and perhaps galactogogues 
internally. Among the various articles included under this head Dr. R. distin- 
guishes especially decoction of the leaves and stalks of the castor-oil plant, 
an infusion of fennel-seeds, etc. etc. 

The remainder of the treatise is devoted to a consideration of the nature and 
treatment of the atrophy of infants resulting from errors in diet and regimen. 
According to Dr. R., it is the power of primary assimilation, or digestion in the 
alimentary tract only which is lost, while secondary assimilation, or the absorp- 
tion and appropriation of assimilable matters, if such be present, may still be 
effected. It is, therefore, manifest that ordinary dieting will never suffice to 
restore the child. Starchy matters, which are so generally prescribed, should 
not be given. In the morbid condition under consideration these substances 
cannot undergo in the stomach the normal changes necessary to their proper 
assimilation. How far the same is true in respect to sugar must be determined 
by future inquiry. Glucose is probably occasionally digested in these jases. The 
albuminous matters, particularly the casein and oily substances that are taken, 
do not seem to be digested any better than starchy matters. Milk passes 
off by the bowels in many instances only curdled, but otherwise unchanged. 
This is a state of things peculiar to the disease under consideration; it is not 
met with in other analogous atrophies in infants, to the same extent at least. 
Even the attempt to feed the patients on breast-milk has failed : they seem 
neither able nor willing to take it. 

It will be impossible for us to follow Dr. R. in the details of the treatment 
laid down by him for the form of atrophy in question. His suggestions in rela- 
tion to the use of artificial gastric juice to aid the stomach in the solution and 
assimilation of albuminous substances, and of artificial pancreatic juice, or of 
the phosphate of soda to assist in the digestion of fatty matters, and perhaps of 
sugars also, are deserving of a careful examination. The emulsion of fats may be 
effected also, he remarks, by giving to the patient only the fatty acids of which 
they are composed, and which are readily absorbed into the system. The good 
effects of cod-liver oil are probably in some measure due to its excess of fatty 
acid. The same is true of butter. Many children, it is well known, grow fat 
upon bread and butter. They appear, indeed, to thrive on it when all other 
means fail. 

To correct acidity of the alimentary canal Dr. R. recommends lime-water, 
and to counteract the flatulence and colicky pains, some light carminative, or, in 
severe cases, wine whey made by adding to two parts of boiling milk one of 
good sherry or port wine. 

The best article of diet in these cases is the milk of the human female, or when 



1861.] B.OUTH, Infant Feeding and its Influence on Life. 



255 



this cannot be furnished at all, or only to an insufficient extent, that of the ass, 
goat, mare or cow. When the infant is to be fed on cow's milk, we should 
always endeavour to obtain it from an animal at grass. It should be given to 
the child diluted with water, one or two pints to one of the milk, according to 
the age of the child ; diminishing of eourse the extent of dilution as the child 
becomes older. If two parts of water be used for dilution, sugar should also 
be added in the proportion of one to two drachms to every pint. To each pint 
of the diluted milk, from one to one and a half ounces of lime-water should be 
added to neutralize the amount of acidity present. Which amount may be 
generally determined either by testing the milk with litmus paper, or more 
accurately perhaps, by the symptoms observed in the child — frequent hiccough, 
and apparent griping especially after feeding, as evinced by an occasional cry, 
and sometimes the drawing up of the legs, followed generally by a loose green- 
ish stool. Vomiting is usually present, the ejected matters having an intensely 
acid smell. These premonitory symptoms, if neglected, will be succeeded by 
confirmed diarrhoea. In these cases lime-water in excess is indicated. All 
admixtures of vegetable matters are improper excepting as correctives of bad 
milk. 

Dr. E. gives proper directions for estimating and correcting inferior kinds of 
milk by arrow-root and cream. Occasionally, where diarrhoea is very obstinate, 
rice-water he directs to be substituted for ordinary water as a diluting medium. 

Xow and then, he remarks, not only is diarrhoea present, and intense debility, 
but also great irritability of stomach. Xo kind of food is retained, not even 
wine whey ; even those substances, perhaps, which have hitherto agreed best 
with the child can no longer be borne. The best aliment in these cases, accord- 
ing to Dr. R., is raw meat. It often settles the stomach and alimentary canal 
when all else is rejected by vomiting. Dr. R., after some years of experience, 
has come to regard it as one of the best and surest remedies we possess in such 
cases. 

We will now give, very nearly in his own words, the remarks of Dr. R. on the 
medicinal treatment of defective assimilation. 

In the milder cases all that is required is a proper attention to diet and regi- 
men. The occasional use of carminatives, with half a teaspoonful of castor oil 
when needed, and small doses of alkalies, will often remove the irritability of 
the alimentary canal. Cod-liver oil is usually beneficial; it may be given after 
meals, in teaspoonful doses, with the addition, if there is much acidity, of one, 
two, or more drops, according to the age of the patient, of liquor potassas. In 
some cases, where there is indigestion, the oil may, with great advantage, be 
combined with from a half to one teaspoonful of the essence of rennet. In 
more severe cases, and if diarrhoea be present, Dr. R. pronounces the nitrate of 
silver, in doses of one-sixteenth to one-eighth of a grain, to be, without doubt, 
the best remedy; sometimes the sulphate of copper in similar doses proves 
.effective. He places little confidence in catechu, logwood, chalk mixture, or 
opium. Anodynes he considers to be sometimes useful. Thus, when a child 
cannot rest or sleep, they are imperatively called for. The nervous child is over- 
excited — it needs to be calmed: two to five drops of tincture of henbane, in a 
teaspoonful of dill water, at night, will suffice. Often, after a week or ten days, 
the child will be found to rest without its further use. Opium is more certain, 
but it is, at the same time, a much more dangerous remedy in the case of infants. 
Dr. R. has seen two children killed by it ; in one of the cases a single drop of 
laudanum constituted the fatal dose. He thinks, however, that when given in 
quarter-drop doses gradually increased and carefully watched, these unfortunate 
results from the use of laudanum will seldom occur. 

Defective assimilation is sometimes attended with feverish excitement ; which 
usually comes on at night, and is no doubt due in great measure to the gastric 
irritation. In such cases, we are assured, that external inunctions of oily or 
lardaceous substances prove most effective remedies. The rationale of the 
curative operation of these substances is not yet satisfactorily explained, but 
of the fact, according to Dr. R., there can be no doubt. Thus, if the child be 
completely rubbed over with a mixture of suet and sweet oil, of such a consis- 
tency as will allow it to remain on the surface, in about three hours' time, or 



258 



Bibliographical Notices. 



[July 



even before, the skin will be found to have cooled and become soft ; the anorexia 
to have disappeared, while often a quiet comfortable sleep will soon follow. 
The next morning the child should be washed in a warm bath. Two or three 
applications of the inunction, it is said, will generally effect a cure of the feverish 
excitement, and the irritation of the alimentary canal is usually at the same 
time greatly benefited. Dr. Simpson, of Edinburgh, has shown the good results 
derived from external inunction of cod-liver oil when the remedy could not be 
taken internally. When, in cases of defective assimilation, in connection with 
the emaciation, there are attacks of hectic fever, frictions of the surface with 
cod-liver oil will often remove both symptoms, and greatly improve the general 
health of the patient. Milk baths in cases attended with dyspepsia and great 
emaciation have been found most effective remedies. Dr. R. presumes that in 
these cases, absorption of the fatty and nutritive matters takes place through 
the skin. Nutritive injections are sometimes beneficial where food cannot be 
taken into or retained upon the stomach. Life has been prolonged by them 
until the irritation of the stomach has subsided, and aliments could be again 
taken in the ordinary way. Even cod-liver oil may be absorbed if given in an 
injection. 

In respect to the treatment of the aphthae by which defective assimilation is 
so often accompanied, Dr. R. remarks, that "the mild form will generally yield 
to borax and honey, weak solutions of alum, and the other remedies employed 
ordinarily in thrush. The other variety, the malignant or contagious, is a much 
more serious affection ; it more closely resembles diphtheria, and requires an 
analogous treatment. Generally wine whey, or wine, should be given freely. 
As local applications, the only remedies which in my hands have cured have 
been, first, a weak solution of nitrate of silver, applied by means of a sponge 
all over the affected parts, twice or three times a day; secondly, the tincture of 
sesquichloride of iron, in strength varying from one part of the tincture in from 
seven parts to an equal quantity of water. In cases where the throat or nasal 
mucous membranes are covered with these aphthae, I have used a fine syringe, 
and injected sparingly, either down the throat or up the nasal cavity, the weaker 
solution. * * * Such local and general treatment, however, must not super- 
sede the hygienic. Pure air, isolation, the free use of disinfectants, and scrupu- 
lous cleanliness, are also needed ; in fact, every measure is to be taken which will 
in any way prevent the development of that infantile hospital atmosphere which 
is always observed wheresoever many children are congregated together, and 
which proves invariably deadly in its effects." 

We recommend an attentive perusal of the treatise of Dr. Routh by every 
physician. It is certainly replete with instructive facts and practical deductions 
regarding the proper feeding of infants — the morbid conditions resulting in 
them from improper and deficient nutriment, and the means best adapted for 
their correction. We know of no treatise in which these subjects — which are of 
the deepest interest to every medical practitioner — are treated in a more able 
and philosophical manner;— no one, indeed, which throws so great an amount 
of light upon every question connected with the proper dietary of the early 
periods of existence. Our anyalsis of it has been necessarily confined to a bare 
outline; it but imperfectly indicates the exceeding riches of the volume and the 
sound practical sense by which it is characterized throughout. D. F. C. 



Art. XXIV. — On the Signs and Diseases of Pregnane!/. By Thomas Hawkes 
Tanner, M. D., F. L. S., Member of the Royal College of Physicians, etc. etc. 
12mo. pp. 504. London, 1860. 

In this volume Dr. Tanner has presented a very fair exposition of the actual 
condition of our knowledge in regard to the subjects indicated on its title-page. 
Whether such a work was called for in order to supply a want in medical litera- 
ture, or whether all it teaches was as fully and satisfactorily taught in the nume- 



1861.] 



Brandao, Medico-Chirurgical Statistics. 



251 



rous publications already upon the shelves of our libraries, we shall not pause 
to consider. However this may be, it cannot be denied that the author has 
furnished to the obstetrical student and practitioner an admirable digest of all 
that is at present known in regard to the signs and duration of pregnancy, and 
the diseases which simulate it, the causes, phenomena, results, and treatment 
of abortion ; the character of substances, besides the early ovum, occasionally 
expelled from the uterus, with the mode of recognizing each — as, for example, 
moles, solid and vesicular, menstrual decidua, and membranous formations from 
the vagina; extra-uterine gestation; superfcetation, and missed labour; the dis- 
eases which may coexist with pregnancy ; the sympathetic disorders of the lat- 
ter state, and the diseases of the urinary and generative organs, including dis- 
placements of the gravid uterus, liable to occur during gestation. The whole 
of these subjects are embraced in twelve chapters. 

Each is illustrated, whenever it admits of it, by the history of many important 
and appropriate cases, either derived from the practice of the author himself, or 
borrowed, with due acknowledgment, from the writings of others. 

The work of Dr. Tanner, in whatever light it may be viewed, is got up with 
great ability, and as a manual of the signs and diseases of pregnancy it has no 
superior, scarcely perhaps an equal. D. F. C. 



Art. XXY. — Relatorio do Gabinete Estatistico Medico-Chirurgico do Hos- 
pital Geral da Santa Gasa da Misericordia e Enfermarias publicas, Apre- 
sentado Ao Exmo. Sr. Marquez D'Abrantes, Provedor da Santa Casa, pelo 
Dr. Luiz Da Silva Brandao, Director do Gabinete Estatistico, etc. etc. Eio 
De Janeiro, 1860 : 4to. pp. 62. 

Report of the Department of Medico-Chirurgical Statistics of the General Hos- 
pital Santa Casa da Misericordia, and of the Public Infirmaries, etc. By 
Dr. Luiz Da Silva Brandao, Director of the Department of Statistics, etc. 

Although somewhat deficient in the fulness and precision which are so essen- 
tial to the value of all medical statistics, the series presented by Dr. Brandao 
are replete with interest. They present a tolerably favourable exposition of 
many of the leading facts connected with the diseases which prevail among the 
general population of the city of Rio De Janeiro, and its immediate environs. 

The statistics presented in the report before us are for the first six months of 
the year 1860. During that period there were admitted into the hospitals of 
Rio Janeiro, 8,747 patients, while there remained in the wards, on the 31st ^of 
December, 1859, 932 patients, making the total number treated, from the first day 
of January, 1860, to the 30th of June of the same year, amount to 9,679. 
. The general mortality of the hospitals was 18 per cent. 

The statistical tables before us embrace 1223 cases of intermittent fever, 
chiefly of the quotidian type; of these, 11 are reported to have terminated fa- 
tally. 101 cases of typhoid fever, of which 51 proved fatal. Of the eruptive 
fevers, there are reported to have occurred 114 cases of smallpox. Of these, 23 
died. Only two cases of varioloid are reported; both recovered. 

Of yellow fever, the statistics of 1,596 cases are given — 1,482 males, 114 
females; 108 infants, 837 youths, 585 adults, 66 aged ; 1512 whites, 84 coloured; 
187 were natives, 1,356 strangers, and 53 Africans. The deaths amounted to 
495 ; rather more than 31 per cent. Of the fatal cases, 458 occurred in males, 
37 in females, 30 in infants, 264 in children, 152 in adults, and 19 in aged per- 
sons ; 485 in whites, and 10 in coloured persons ; 7 in natives, 484 in foreigners, 
and 4 in Africans. 39 of the cases of yellow fever were, when received, in a dying 
condition ; 72 died within the first 24 hours, and 86 within the first 48 hours. 

506 cases of pulmonary tuberculosis were treated — 388 males, 118 females ; 
27 infants, 261 children, 165 adults, and 53 aged persons; 379 whites, and 127 
coloured; 109 natives, 362 foreigners, 35 Africans. The mortality amounted to 
48.8. 

In the general report preceding the series of statistical tables, under the head 
No. LXXXIIL— July 1861. 17 



258 



Bibliographical Notices. 



[July 



of Yellow Fever, there are some general remarks on the plan of treatment found 
most successful in the control of the disease as it occurred in Rio Janeiro. 

From no treatment, Dr. Brandao remarks, was such beneficial results derived 
in cases of yellow fever, as from the administration in its early stage of sudo- 
rifics and purgatives. When the febrile reaction was very violent, a general 
bleeding was demanded, and when evident symptoms of gastric distress were 
present, an emetic of tartarized antimony. After the bowels had been cleared 
out by the employment of calomel and castor oil, the patient was placed on 
the use of sulphate of quinine, which was given until an entire resolution of 
the febrile symptoms occurred, when the employment of a lemonade made from 
some one of the mineral acids usually sufficed to complete the cure. When 
the disease had passed into the second stage, and vomiting of a bilious or black 
matter, or of blood took place, with suppression of urine, etc., cups, or a large 
blister, were applied to the epigastrium. Internally, may be administered 
tincture of nux vomica, ergotine, perchloride of iron, subnitrate of bismuth, and 
such other tonics and antispasmodics as the symptoms present would seem to 
indicate. Labarraque's solution may also be given by the mouth and by injec- 
tion into the rectum. 

Dr. Viega, Director of the Infirmary Nossa Serihora da Saude, has derived 
great advantage in the relief of the peculiar pain of the head which occurs in 
some cases of yellow fever, from the topical application to the frontal region of 
a solution of cyanuret of potass. 

In a foot-note, again, we are told that the treatment generally pursued varied 
with the several periods of the disease. In the first stage, or within the first 
twenty-four hours after the invasion of the disease, the abortive treatment was the 
one most depended on. That is to say, the object had in view was, by the admi- 
nistration of mild but active remedies to procure large alvine evacuations, and 
to solicit an increased secretion of bile, and thus concur in effecting a decarbo- 
nization of the blood. From 18 to 20 grains of calomel were at first directed, 
followed at the end of two hours by from two to three ounces of castor- 
oil, which is to be repeated after a proper interval, so as to secure copious 
bilious evacuations. So •soon as this has been effected the patient is to be put 
upon the use of a drink formed of a pint and a half of lemonade made from 
sulphuric acid, and half a drachm of sulphate of quinia ; of this a wineglassful 
is to be taken every two hours. 

When the reaction is very violent, and the patient of a plethoric habit, a 
bleeding from the arm will have the effect to render much more effective the 
above treatment. At the same time the application of cups to the gastro-he- 
patic region will be required to diminish the congested condition of the stomach 
and liver. 

During three years, Dr. Brandao has pursued invariably the foregoing treat- 
ment, whenever he has had an opportunity of combating the disease in its pri- 
mary stage, and he has rarely known an instance when such has been the case 
where the disease has passed into the second stage. 

When the patients are received after the second day of the disease, the urine 
already commencing to become albuminous, the irritability of the stomach is 
such that the foregoing treatment can seldom be put in practice. The fluid 
magnesia of Murray, or the carbonate and citrate of magnesia, will sometimes 
be tolerated to an extent sufficient to promote bilious evacuations, at the same 
time the patient should be supplied with cold water or some refrigerant as a 
drink. Sometimes the quinated lemonade will be tolerated. In cases marked 
by a hemorrhagic tendency, or in which the black vomit has already set in, there 
is little chance of recovery. Occasionally, a large blister to the gastro-hepatic 
region, injections impregnated with the solution of Labarraque, and, by the 
mouth, the valerianate of quinia and camphor, small doses of magnesia, and 
cold and tonic infusions when the stomach will tolerate them, have occasionally 
been followed by an entire solution of the disease in even, apparently, desperate 
cases. D. F. C. 



1861.] 



259 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

IN THE 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. On the Physiology of the Valves of the Heart. — Ludwig Joseph, in a pre- 
vious paper (Virchoiv's Archiv., Bd. xiv.), gave a minute anatomical account of 
the valves of the heart, describing particularly the muscular nature of the va- 
rious valves, which was discovered by Kiirschner in 1840. Joseph observed in 
the venous valves muscular elements which proceed from the innermost muscular 
layer of the auricle, and extend into the valves for a third of their length, in the 
form of tongue-shaped expansions. This being the case, it is clear that the 
contraction of the auricles must also influence the position of the auriculo-ven- 
tricular valves ; and since the contraction of the auricles begins at the entrance 
of the great venous trunks, the auriculo-ventricular valves participate in the 
auricular systole towards its termination. The effect of the contraction of the 
fibres in these valves is to draw them up like a curtain against the ostium veno- 
sum, so as to form around the ostia a low, firm, ring-shaped wall. The auriculo- 
ventricular orifices are at the same time somewhat enlarged by this contraction ; 
and by facilitating thus the entrance of the blood into the ventricle, its chamber 
is more easily and completely filled. The action of these valvular fibres may be 
studied in the quite fresh heart of any animal, by applying to the interior of the 
auricle an induction current. The fibres of the heart are attached to the arterial 
rings in the great vessels, the aorta and pulmonary artery, whilst by the other 
ends they terminate in the cordse tendineas. Contraction takes place at both 
ends, and meets in the middle of the fibres. By the contraction of the musculi 
papillares in the centre of the auriculo-ventricular orifice, the points and edges of 
the valves are unrolled, and the occlusion is perfected. The pressure of the blood 
assists also to unfold and to stretch the valves. They form a somewhat convex 
floor to the auricles, and are prevented turning upwards by the influx of venous 
blood, and also by the cordae tendinese. The semilunar valves are much simpler. 
At the beginning of systole the valves are as far as possible removed from the 
sinuses of Valsalva ; they are then separated by the ventricular contraction, and 
this is more easily accomplished than at first sight would appear, for the con- 
traction of the arteries is already over. The valves are not pressed quite close 
against the arterial walls, as many seem to think, and blood therefore remains 
constantly between the valve and the arterial wall. It is this blood behind the 
valves which closes them, and not a returning wave. Of this the author has 
convinced himself by experiment. — Ed. Med. Joimi., April, 1861, from Archiv. 
fur Path. Anat. 

2. Physiology of the Tliymus Gland. — According to Friedleben {Die Phy- 
siologic der Thymusdruse) the thymus increases in size up to the time of pu- 
berty ; although after birth up to that time its size to that of the body is 



2G0 



Progress of the Medical Sciences. 



[July 



relatively less. From puberty to manhood it is stationary ; and after this it 
begins to disappear. Friedleben says the same thing occurs in the lower ani- 
mals. Like Bischoff, Friedleben observed it to be occasionally absent in well- 
developed children. The juice of the thymus, Friedleben says, has always an 
acid reaction — which disappears when the gland begins to putrefy — and the 
ashes left after incineration are only in part soluble in water. They consist of 
chlorides, phosphates, and sulphates of soda, potash, lime, and magnesia. The 
organic matter is albumen, gluten, sugar, fat, colouring matter, and lactic acid. 
The quantity of ash is greater in the calf than in the ox ; the thymus of a calf, 
ten days old, contains 10.226 per cent, of inorganic matter ; whereas that of an 
ox, eighteen months old, has only 3.317 per cent. The quantity of water is also 
greater in the thymus of the calf. A rich diet, of albuminous, fatty, and saline 
food, increases the size of the thymus and the amount of its secretion ; but an 
entirely fatty diet causes it to disappear. Starch diet first increases the secre- 
tion, then diminishes it, and at length causes atrophy of the gland, as happens 
in starved animals. 

Friedleben found that extirpation of the gland is not fatal to young dogs ; and 
that when both the thymus and spleen are extirpated the preparation of the 
blood and the nourishment of the body are defective ; so much so that after a 
time all the animals operated on die of a species of inanition. "When the thymus 
alone is removed the spleen increases in size. The urine is also found to be di- 
minished in quantity. — Sydenham Society's Year-Book of Med. Surg., Sfc, for 
1859. 



MATERIA MEDICA AND PHARMACY. 

3. Administration of Medicines. — The following is the recapitulation of some 
interesting remarks by Dr. Henry Kennedy (Dublin Med. Press) on this sub- 
ject:— 

" 1. To insure the full effects of any medicines, they must be given in larger 
doses than is at present done. 

" 2. As examples of this principle, sarsaparilla, benzoic acid, the dilute nitric 
acid, and the preparations of colchicum, may be mentioned. 

" 3. The adulteration of medicines, or the substitute of cheaper articles, is a 
common cause of their failure. 

" 4. The introduction of new medicines or preparations into practice tends to 
increase the difficulties of therapeutics, by enlarging the field for observation. 

" 5. In testing the effects of medicines, every care should be taken that the 
experiment is an exact one ; and, when possible, the medicine should be given 
per se. 

" 6. When the nature of the substance admits of it, there are good grounds 
for believing the form of powder is the most efficacious in which it can be ad- 
ministered." — British Med. Journal, May 18, 1861. 

4. Use of Glycerine in the Internal Employment of Chloroform. — M. Bonnet 
gives (Journal de Pharmacie, March, 1861) an account of the various means 
he has tried of remedying the inconveniences which attend the ordinary mode of 
prescribing chloroform for internal use ; seeing that, in consequence of its inso- 
lubility in ordinary vehicles, it is administered equably only with difficulty. He 
finds that mixing equal parts of chloroform and the finest glycerine in a mortar, 
until the droplets of chloroform cease to be visible, completely answers the end. 
When water or other adjuvant is added, a limpid fluid is produced, which 
exhibits no sign of separation, even when more than 100 parts by weight of the 
chloroform are added to distilled water. It is essential for this that the glyce- 
rine shall be perfectly pure. Sulphuric ether may be administered in the same 
way. For external application, chloroform should be combined in the same 
way, a larger proportion being caused to be taken up by more rubbing. This 
preparation of the chloroform prevents the painful irritation which sometimes 
ensues on its application. — Med. Times and Gaz., April 27, 1861. 



1861.] 



Materia Medica and Pharmacy. 



261 



5. Action of Chloroform. — Dr. Sansom read a paper on this subject before 
the Royal Medical and Chirurgical Society, April 12, 1861. The following are 
his conclusions: "1st. That chloroform-narcotism is due to the imperfect stimu- 
lus to the vital functions of a mal-oxygenated blood. 2d. That this mal- oxyge- 
nation is due to the direct influence of the vapour of chloroform upon the blood, 
and especially upon the blood-corpuscles. 3d. That the vapour acts caustically 
on the cell-walls of the blood-corpuscles, and thus impedes the endosmosis of 
oxygen. 4th. That if the blood be so deteriorated as to supply an insufficient 
stimulus to the heart, death is by syncope ; whilst if stasis be primarily effected 
in the lungs, death is by apncea " — Med. Times and Gaz., April 20, 1861. 

6. Celandine as a Vulnerary. — The ancients made great use of this plant; and 
it is probably unjustly neglected at the present day, since it possesses active 
principles which afford the presumption of unequivocal therapeutic properties, 
and require only the application of exact chemical experiment. Dr. Saco, 
chemist at Wesserling, has lately directed the attention of practitioners to the 
topical effects of the plant. According to him, the action of celandine as a 
vulnerary is greatly superior to that of arnica. In the south, the chelidonium 
majus is universally employed to prevent or subdue traumatic inflammations ; 
and that, says M. Sacc, with a certainty which he has not witnessed in any other 
vulnerary. At Marseilles, where it is always found in full vegetation, it is the 
popular cure ; and M. Sacc quotes several cases showing its excellent topical 
effects. In northern countries, he recommends the preparation of an alcoholic 
tincture of the leaves. Unless we are mistaken, however, the chemical analyses 
of MM. Chevalier and Lassaigne have proved that the root is more rich in the 
active principles ; and it would therefore be preferable to employ that part of the 
plant.— Ed. Med. Journ., March, 1861, from Bull. Gen. de Therap., Nov. 1860. 

7. Method of Making Endermic Applications. — The following is M. Trous- 
seau's plan. He removes the epidermis by means of strong ammonia : but the 
application requires caution ; if the ammonia be too long applied, it will leave 
a scar. A thimble is filled to four-fifths with cotton-wool, and then a little 
pledget soaked in the strong liquid ammonia fills up the remaining fifth. It is 
then placed on the part affected and kept in contact with the skin for a shorter 
or longer time. Two minutes suffice for its application behind the ear, three 
minutes on the temples, four to five on the neck. The mode of dressing the 
blister thus formed is the grand point. M. Trousseau never applies the salt, 
etc. in powder ; he mixes the powder into a paste with a drop of water, in the 
palm of his hand, and then spreads it on the surface from which the blistered 
epidermis is wiped off. He then covers the application with oil-silk to keep it 
moist, and with diachylon. After twelve hours the dressing is renewed ; but 
first the false membrane formed must be carefully removed, or absorption will 
• not take place. — Brit. Med. Journ., April 13, 1861. 

8. Distilled Wafer of Copaiba. — Dr. E. Langlebert employs a distilled water 
of copaiba, prepared according to the ordinary process, both for internal use and 
as a vehicle for substances to be injected in gonorrhoea. The dose is from five 
to seven ounces daily. It is borne well. For injection, he combines it with 
sulphate of zinc, tannic acid, tincture of catechu, etc. — Bull. G6n. de Th6r., 
March 15, 1861. 

9. Chlorate of Potash and Glycerine as a Topical Disinfectant. — Experi- 
ments instituted at Bic^tre, under the direction of M. Martinet, have demon- 
strated remarkable disinfecting properties in a mixture of chlorate of potash and 
glycerine according to the following formula : Chlorate of potash in powder, 2^ 
drachms ; glycerine, 3 ounces ; mix. This mixture has been shown, by repeated 
trials, to present, 1st. A marked disinfecting power, due perhaps to the change 
which it produces in the secretion, and the mode of action of the wound ; 2d. 
The property of giving the pus, even when of a serous kind, a greater consistence, 
often like cream. This result is, perhaps, according to M. Martinet, a physical 
effect of the affinity of glycerine for water, which it subtracts from the pus ; but 



262 



Progress of the Medical Sciences. 



[July 



is partly due to the favourable modification which is produced in the suppurating 
surface. He is inclined to think that the preparation of glycerine and chlorate 
of potash may, by thickening the pus, tend to prevent the occurrence of puru- 
lent or putrid infection, which generally takes place in connection with suppura- 
tion of a serous and unhealthy character. An advantage of the glycerine is, 
that it prevents the dressings from sticking to the edges of wounds. According 
to M. Martinet, the glycerine chlorate of potash is not adapted for wounds or 
sores of a bright red colour, nor for those that are recent or of healthy appear- 
ance. — Edinburgh Med. Journ., March, 1861, from Bull. Gen. de TMrap., Nov. 
1860. 



MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL 

MEDICINE. 

10. Hypophosphites inthe Treatment of Phthisis. — Dr. James Risdon Bennett 
has given (Med. Times and Gaz., Ap. 27, 1861) some interesting results of trials 
of the hypophosphites, recommended by Dr. Churchill in the treatment of 
phthisis, and relates twenty cases, taken without selection, of which' he happens 
to have more or less complete notes treated by the hypophosphite of soda. Of 
these twenty cases there were only nine in which the disease did not steadily 
advance while under treatment, and of these, four only manifested any decided 
improvement, while of the permanency of the improvement of these four, Dr. B. 
lias no proofs, he says, in any one instance. 

" I have tried," he states, " the remedy in numerous other cases besides those 
of which notes have been preserved, but have not been able to discover that it 
has exerted any special influence on any one function of the body, unless, indeed, 
it be on the digestive function. In many instances the tongue has improved in 
appearance, and the appetite increased, while the patients have been taking the 
remedy. But I question whether this has not been as much from the abstinence 
from all remedies capable of deranging the stomach, as from any direct influence 
exerted by the phosphatic salt. 'Where the stomach has been irritable, or where 
the state of the system has been such that all tonics have more or less disagreed, 
and where, consequently, these have been abandoned, temporary improvement 
has often followed the exhibition of the hypophosphites. In many of these in- 
stances the patients would probably have been as well with a little lime-water, 
citrate of potash, or any other equally innoxious agent. And, indeed, it often 
enough occurs in the course of the treatment of phthisis, that patients are for a 
time, at least, better without any medicine, simply regulating their diet. But 
even assuming that the new remedy has been useful in allaying irritability of the 
stomach, or improving the digestion, such effects often result from small doses 
of the alkalies, and may, therefore, in all probability, be referred, in the instances 
in question, to the base, rather than to the acid with which it is combined. In 
some cases, increased secretion of urine followed the use of the remedy, but this 
increase was not more than might be accounted for by the subsidence of febrile 
disturbance. In no case did I find that the urine was rendered acid, but in some 
instances it became slightly alkaline, or neutral, where it had before been acid. 
In no instance was there any evidence of excitement of the pulse, or tendency 
to haemoptysis induced, nor any direct sedative influence exerted on the local 
pulmonary irritation. Haemoptysis has, indeed, occurred while the patients 
have been taking the remedies, but in circumstances not justifying the belief 
that the remedy had anything to do with exciting the hemorrhage. 

"The hypophosphite of lime, I have said, has appeared to me, on the whole, 
more useful than the salt of soda. Lime-water is well known to be very useful 
in many cases of gastric derangement, attended by nausea, vomiting, or gas- 
tralgia, and I have lately given, with advantage, in many such cases, a saccha- 
rine solution of lime, prepared for me by Messrs. Warner and Barclay, according 
to a formula recommended by Dr. Clelland, in the Edinburgh Medical Journal, 
for August, 1859. In several instances where the irritability of both stomach 



1861.] Medical Pathology and Therapeutics. 263 

and bowels has been such as to interfere with all treatment, and with the taking 
of the most simple food, and where, consequently the emaciation and debility , 
have rapidly increased, I have found the saccharated solution of lime, in doses 
of from twenty to thirty minims, three times a-day, prove of signal service. And 
it has appeared to me to act, not merely as an antacid, but as a tonic. I think 
it, therefore, extremely probable that the hypophosphite of lime will prove in 
many cases a useful remedy in the treatment of phthisis, acting beneficially on 
the stomach and intestinal mucous membrane, and, as Dr. Churchill affirms, on 
the pulmonary mucous membrane, diminishing the expectoration, and giving 
tone to the capillaries. 

" But I am bound to say, that I have seen no more evidence of any specific anti- 
tubercular action exerted by the salt of lime than by the soda salt. No one 
will be inclined to question the great value of tonics in the treatment of phthisis, 
and among the poor, or those who have either neglected or mismanaged them- 
selves under the false notion that tonics and good living are not suited to the 
cough, and other symptoms attendant on phthisis, it is often marvellous to ob- 
serve the rapid improvement, and, perhaps, apparent cures, that follow on the 
administration of tonics. But it is not less true, that we meet with many cases 
of phthisis where tonics are not borne, and where their action is even highly 
injurious. This is especially the case with steel, which is often very injudiciously 
given. A trial of the hypophosphites may be useful in elucidating the benefit 
that accrues, in many instances, from a temporary or even an entire, abandon- 
ment of all tonics, and adherence to regulated diet, and all the various hygienic 
means, of such paramount importance in the management of all cases of tuber- 
cular disease." 

11. Action of Liquor Potassce upon Phthisis. — In our No. for Jan. last, p. 
261, we gave the results of some trials made by Dr. R. P. Cotton, Physician to 
the Hospital for Consumption, to ascertain the effect of hydrochloric acid on con- 
sumption. This careful observer has lately published (Med. Times and Gaz., 
April 13th, 1861) some experiments on the (chemically) opposite treatment by 
a pure alkali, on the same number (25) of unselected hospital patients. 

He " administered fifteen minims of liquor potassae two or three times a day, 
sometimes slightly increasing each dose. Of the patients ten were males and 
fifteen were females ; their ages varied from fifteen to forty years ; eight of them 
were in the first stage, four in the second stage, and thirteen in the third stage 
of the disease. 

" Of the twenty-five cases, two slightly improved ; one greatly improved ; and 
twenty-two appeared to be uninfluenced by the treatment. In only one instance, 
however, did it disagree with the stomach ; in all the rest it seemed to be in- 
operative either for good or harm. In the two slightly improved cases quinine 
and iron were afterwards administered with a more satisfactory result ; and in 
•the one greatly improved, the liquor potassae was changed for a vegetable 
tonic, without any alteration in the general progress. Eight patients gained 
slightly in weight ; nine lost weight ; and eight experienced no change in this 
particular. 

" Of the twenty-two patients in whom the liquor potassae seemed inoperative, 
nine improved under a change of medicine, some of them, indeed, to a marked 
extent ; thirteen, however, experienced no amendment under the like change, 
being apparently in a condition of disease hardly amenable to any kind of treat- 
ment. 

" With this result, it may be interesting to couple a statement contained in 
the preceding report, that four patients who had been deriving benefit under 
the influence of dilute hydrochloric acid, unhesitatingly declared that they pro- 
gressed to a much less extent during the brief period in which this remedy 
had been experimentally changed for liquor potassce. 

" In the days of some of our professional ancestors, liquor potassae enjoyed a 
considerable reputation as a remedy in phthisis, from its supposed so-called 
" deobstruent" action. Of late years, however, it has fallen, I believe, compara- 
tively into disuse, and is not often prescribed, except perhaps to meet an occa- 
sional complication. 



264 



Progress of the Medical Sciences, 



[July 



" To these experiments, as well perhaps as to some which have preceded them, 
it may possibly be objected, that the period of trial was not sufficiently pro- 
longed. From a conviction, however, that the time spent within an hospital is 
too valuable to the patients to be unnecessarily sacrificed to experiment, it has 
always been my habit not to persist with any one treatment for a longer period 
than two or, at most, three weeks, whenever it appeared that the patient was 
deriving no benefit, or when it seemed probable that the use of some other 
medicine might be followed by a happier result. 

"It would be foreign to the object of this communication to enter upon 
the action of any of the salts, either of potassa or the other alkalies. I may 
briefly remark, however, that for certain dyspeptic complications of phthisis, 
several of these rank very highly as remedial agents. 

" From the preceding observations, coupled with the results already obtained 
from the use of hydrochloric acid, as recorded in my last communication, I think 
we may fairly arrive at the following conclusions : — 

"1. That liquor potassae, in moderate doses, rarely disagrees with consump- 
tive patients, but is quite as rarely productive of any good effect. 

" 2. That the so-called tubercular crasis is very much more likely to be re- 
lieved by the mineral acids than by the alkalies." 

12. Influence of Ozonized Cod-liver Oil on the Pulse. — Dr. E. Symes Thompson 
read an interesting practical paper on this subject, before the Royal Med. and 
Ohirurgical Society (Feb. 26th, 1861). He commenced by reminding the society 
of a paper by his father, Dr. Theophilus Thompson, published in the Transac- 
tions 1 (vol. xlii.), in which the attention of the profession was first drawn to this 
subject. He recorded the cases of about twenty patients at King's College 
Hospital, to whom the ozonized oil was administered. The usual dose was 
two drachms twice a day. Scarcely any effect was observed from doses of one 
drachm. The influence of the oil on the pulse increased in proportion to the 
dose in which it was given, the effect of half-ounce doses, two or three times a 
day, being more marked than that of smaller quantities. The following table 
exhibits, as simply and concisely at possible, the results : — 



Table showing the Changes of Pulse under Ozonized Cod-liver Oil. 



Name. 


Sex. 


Disease. 


Time of 
taking Oil. 


Pulse. 


Days. 


Before. 


After. 


J. P. 


M. 


Phthisis, first stage. 


7 


116 


98 


J. s. 


M. 


Ditto. 


7 


120 


108 


W. B. 


M. 


Tuberculous larynx. 


21 


112 


92 


M. H. 


F. 


Phthisis, second stage. 


7 


80 


80 


E. A. W. 


F. 


Ditto. 


14 


140 


112 


C. H. 


F. 


Phthisis, first stage. 


14 


100 


104 


R. N. 


M. 


Phthisis, third stage. 


7 


150 


116 


E. D. 


M. 


Phthisis, second stage. 


7 


138 


112 


J. O'D. 


M. 


Emphysema. 


4 


104 


86 


M. M. 


F. 


Phthisis, second stage. 


5 


140 


108 


E. R. 


F. 


Ansemia. 


4 


120 


116 


M. S. 


F. 


Phthisis, third stage. 


2 


94 


92 


E. H. 


F. 


Phthisis, second stage. 


10 


104 


88 


W. S. 


M. 


Phthisis, first stage. 


7 


104 


104 


P. R. 


M. 


Phthisis, third stage. 


4 


104 


96 


S. E. 


F. 


Phthisis, second stage. 


20 


120 


92 


Gr. M. 


M. 


Phthisis, third stage. 


4 


140 


120 


H. C. 


F. 


Phthisis, first stage. 


2 


108 


95 


W. H. 


M. 


Phthisis, first stage. 


5 


120 


96 


J. R. 


M. 


Phthisis, first stage. 


9 


120 


98 



» See No. of this Journal for Oct. 1859, p. 529. 



1861.] Medical Pathology and Therapeutics. 



265 



The author also recorded the effects of ozone in another form. He had made 
use of the ozonized water (as prepared by Condy), and found its influence in 
retarding the pulse considerable. In reference to a belief still prevalent amongst 
some members of the profession that ozone was a high oxide of hydrogen, the 
author remarked that he had used the peroxide of hydrogen (prepared by 
Messrs. Bullock), and found that it exerted no special influence on the pulse, 
which was more often accelerated than retarded under its use, which seemed to 
corroborate the conclusions of Dr. Andrews, who showed (in the Philosophical 
Transactions of the Royal Society, vol. cxlvi. p. 1 et seq.) that ozone was not 
an oxide of hydrogen, but simply an allotropic modification of oxygen. Of the 
20 cases in which ozonized oil was given, in 11 the pulse was reduced more than 
20 beats a minute ; in 4, upwards of 10 beats ; in 1, no effect was produced ; 
and in 1 only was any permanent acceleration observed, and this could only be 
fully accounted for by disturbing circumstances. Of the 7 cases in which 
ozoDized water was given, in 3 the pulse was lowered more than 20 beats, in 3 
about ten beats, and in 1 it was at one time retarded and at another accelerated. 
Dr. Thompson drew special attention to the importance of the inquiry as con- 
nected with the treatment of phthisis, since, in this disease, anything that could 
retard the excessive rapidity of the vital changes would likewise check the 
development and progress of the disease. He showed that this had long been 
realized by the profession, and mentioned several remedies that had been used 
for this end, especially digitalis, which, though useful in some cases, was greatly 
inferior to ozone, being both less certain in its actioD, and often dangerous, from 
its cumulative tendency ; while ozone exerted on the heart, not a depressing, 
but a strengthening and invigorating influence. It was suggested that the ex- 
planation of the remarkable effect of ozone in phthisis might be found in the 
greater affinity which phthisical blood had with oxygen — an affinity which it 
also preserved when in the allotropic form of ozone. Before concluding, the 
author alluded to a paper recently published by a French physician, On the 
Use of Ozonized Oil of Turpentine in Hemoptysis, in which the suggestions 
made by Dr. Theophilus Thompson, in 1859, had been followed, and observed 
that he had himself prescribed turpentine with ozonized cod-liver oil in hemop- 
tysis with much benefit. — Med. T. and Gaz., March 9, 1861. 

13. Acetate of Lead for Pneumonia. — Prof. Steohl, of Strasbourg, extols 
the use of acetate of lead in cases of pneumonia,.as much preferable to antimony 
or any of the more ordinary plans of treatment. He prescribes the acetate of 
lead in repeated doses of from three to seven and a half grains. At the com- 
mencement, if the patient be plethoric, he orders a bleeding from the arm, but 
in most cases he is satisfied with cupping or leeches. As soon as the symptoms 
begin to improve, the lead is omitted, and resolution is left to nature, the patient's 
strength being, at the same time, supported by nourishing diet. — Brit. Med. 
■Journ., 27 April, 1861, from Gaz. des Hop., Feb. 28, 1861. 

14. Arseniate of Soda in Scrofula. By Dr. Bouchut. — The manifestations of 
the scrofulous diathesis are all exceedingly inveterate, and the treatment directed 
for their cure is only too often unsuccessful. All forms of scrofula, however, are 
not equally obstinate. The tertiary forms, which appear as tuberculosis, are 
generally incurable ; of the other forms, whether primary or secondary, those which 
affect the bones are especially tenacious and of long duration ; and, in truth, it 
is only over the mucous, glandular, and cutaneous manifestation of scrofula, that 
therapeutics can exert any decided power. The author has used, in turn, all 
the medicines usually reputed anti-scrofulous : iodine, mercury, iron, baryta, 
bromine, extract of walnut leaves, cod oil, arsenic, etc. ; but, of all these agents, 
the arseniate of soda has appeared to him to be, under the circumstances which 
he describes, the most energetic and the most efficacious. In suitable doses, 
arsenic is one of the best tonics and corroborants we possess ; it is only in too 
large doses, or when its use is too long continued, that it deserves to figure as 
an alterative. As a tonic it is an admirable succedaneum of iron, quinine, and 
cod-liver oil ; and is of great service in the majority of organic and nervous ca- 
chexias. In the scrofulous cachexia it is an excellent remedy ; and under its 



266 



Progress of the Medical Sciences. 



[July 



influence children ordinarily regain their appetite, strength, and colour. In such 
cases there is amelioration only ; but the cases where it cures are those in which 
the diathesis has not as yet produced a cachectic condition, and where the local 
manifestations are superficial and confined to the skin, the mucous membranes, 
and suppurated lymphatic glands. Beyond these, in tuberculosis and the dis- 
eases of bones, it is only a good palliative. But, although thus limited, the 
therapeutic effects have considerable importance. It is no slight matter to be 
able to abridge the duration of a coryza, an ophthalmia, or the suppurations of 
glands, cutaneous ulcers, otorrhceas, leucorrhceas. etc., which depend upon the 
scrofulous constitution. The author possesses a number of facts relating to such 
cases, as well as to scrofulous perforation of the palate, reputed syphilitic, sup- 
purating cervical glands (formerly called e'crouelles), etc. The result in all of 
them was the same ; a rapid cicatrization of the sores was always observed. 

In all these cases the arseniate of soda was begun in doses of 5 milligrammes 
(l-14th grain), and increased at the end of a few days to 10, 15, and, finally, 20 
milligrammes (| grain). Beyond that dose, symptoms of gastralgia, vomiting, 
and diarrhoea are apt to come on, and should be guarded against. It may be 
given in gum julep, in Bordeaux wine, in syrup of cinchona, or syrup of gum. 
The following formula may be employed, and the medicine left in the charge of 
families, for use during several weeks : Syrup of cinchona, 300 grammes (.fx); 
arseniate of soda, 5 centigrammes (gr. j): one or two teaspoonfuls each day; 
each teaspoonful containing about 1 milligramme (^ grain) of the arseniate of 
soda. In this dose, and with the precaution of increasing it gradually, the arse- 
niate of soda presents no danger. Its effects are, to increase the appetite and 
produce a richer sanguification, manifested by a ruddy colour of the skin, mus- 
cular energy, and an unmistakable appearance of health. Such results, says the 
author, are not to be despised in the case of scrofulous subjects, pale, emaciated, 
and exhausted by long suppurations and mucous discharges ; and it is on these 
grounds that he recommends the arseniate. He does not propose it, however, 
as a specific, but only as a tonic or corroborant, which stimulates the appetite 
and imparts increased activity to the molecular nutrition of the tissues. In 
scrofulous constitutions, it is the slowness of the movements of nutrition, and of 
the exchange of the circulating materials, which gives the diseases their pecu- 
liarly chronic character. In this respect the arsenical medication is useful, as 
perhaps the cod-liver oil is also, by stimulating nutrition ; and the results ob- 
tained should induce practitioners to have recourse to it. It must be noted, 
however, that the arseniate of soda is suitable only in scrofulous diseases of the 
cutaneous, mucous, and glandular textures. Its efficacy is doubtful in diseases 
of the bones ; and it is only a palliative in the case of tertiary scrofula, that is, 
in tuberculization. — Edinburgh Med. Journ., March, 1861, from Bulletin Gen. 
de Therap., Nov. 1860. 

15. The Grape Cure. By Dr. Aran. — Grapes were used therapeutically by the 
ancients ; but the special application of them to the treatment of certain classes 
of disease dates only about twenty or thirty years back, and is confined, as is 
well known, to certain localities of the Continent. The method is thus described : 
The grape cure, as understood in Switzerland and Germany, consists in making 
grapes the basis of the alimentation during an interval of time extending from 
two to five or six weeks. The cure itself may be strong or mild. In the strong 
cure, the arrangements are as follows: The patient rises very early in the morn- 
ing, and, after having swallowed a large glass of cold water, he goes, if he has 
sufficient strength, into the vineyard, where he eats one or two pounds of grapes, 
pulled from the vines, and still wet with the morning dew; these he eats without 
bread, or, if his stomach has difficulty in supporting the grapes alone, he may 
take a small roll of half an ounce to two ounces. After this repast, the patient, 
according to circumstances, is either subjected to frictions over the whole body, 
or he takes a bath, or he engages in gymnastic exercises, or he simply takes a 
walk. At eleven o'clock, another repast, consisting of three or four pounds of 
grapes; after which again a walk ; and at two o'clock a frugal meal, composed 
chiefly of herbs, with grapes for dessert. In the afternoon, another repast of 
grapes of three to four pounds. Lastly, before going to bed, from one to three 



1861.] Medical Pathology and Therapeutics. 267 

pounds of grapes are taken, with some very light food. The mild treatment 
differs from the preceding or strong cure, only in the smaller amount of grapes 
which the patient takes, the quantity being reduced, according to the case, to 
one-third or one-fourth ; and, besides, a little meat, not too fat, is allowed at the 
midday meal, and a cup of coffee or chocolate in the morning. In both kinds of 
cure much stress is laid upon the regimen. Patients are strictly forbidden to 
take milk, or food made with milk ; all kinds of fat meat, eggs, vegetables, and 
every kind of fruit except the grape, are prohibited ; the day must be regularly 
employed, with moderation both in drinking and eating; no excess of any kind 
is permitted ; and frequent baths are taken. When the cure is finished, patients 
should continue the same kind of life during several weeks — eight or ten ; which 
constitutes what the Germans call the after-cure [Nach-cur). The grape used 
must be perfectly ripe ; and different kinds are used in different countries — the 
chasselas grape in most parts of Germany and Switzerland, the muscatel grape 
in the southern countries. The season best adapted for this treatment is the 
after-season, the middle or end of October, not only because at that time the 
grape is perfectly ripe in favourable years, but also because the air is then 
cooler and more pure, and the patients are less exposed to the heat of the sun 
when they are out in the vineyards, and because the temperature admits of long- 
walks and gymnastic exercises. The localities selected for these special modes 
of cure, of which the number is very considerable at the present day, are, for the 
most part, admirably chosen, both as regards the purity of the air, the beauty 
of the situation, and the exposure, which shelters them from sudden chills of 
temperature. We have only to mention Yeytaux, Montreux, and especially 
Aigle, on the borders of the Lake of Geneva ; on the banks of the Rhine or its 
vicinity, Armenhausen, Bingen, Boppart, Laubbech, and Rudesheim, Saint 
Goar ; Meran in the Tyrol, etc. All acquainted with these countries will under- 
stand how many favourable influences are at work, in addition to the simple 
" grape cure." Theoretically, the grape cure has been attempted to be explained 
on the same chemical principle as the whey cure — viz., that, containing very 
little nitrogen, it was adapted for diseases with predominance of that element. 
But this explanation rests on no ascertained grounds. The grape cure has been 
much vaunted in chronic diseases, phthisis pulmonalis, scrofula, gout, diseases 
of women, diarrhoea, and (what appears very opposite) abdominal plethora, 
haemorrhoids, hypochondria, etc. M. Aran is of opinion that, as a kind of aliment 
of very easy digestion, the grape cure may be serviceable in many diseases, but 
especially in dyspepsia, and other affections of the digestive organs, where it is 
important to give rest to the intestinal canal, while furnishing, at the same 
time, a kind of diet sufficiently nutritious and slightly stimulant. The hygienic 
conditions of the localities are, also, undoubtedly favourable for most chronic 
diseases ; and the author thinks that the plan might with advantage be tried in 
France, so as to ascertain its real value. In the meantime, he is not disposed 
to allow any specific influence to the grape diet, in the cure of these cases, and 
recommends a cautious reserve. Fashion, he adds, has had more to do with it 
than science : and what she has raised up one day, she may overturn the next. — 
Edinburgh Med. Journ., March, 1861, from Bull. Gen. de Therapeutique, Oct. 
1860. 

16. Typhoid Fever and its Treatment. — Professor Pfeufer, of Munich, has 
published an analysis of the cases of typhoid fever admitted into his clinique 
during the winter six months of 1856-7. The cases amounted to 231, a number 
which indicates about the ordinary prevalence of the disease in Munich. Of the 
231 cases, 119 were of a slight nature, while 112 were severe ; and among these 
last there were twenty deaths. In seven of the cases there was a distinct relapse 
of the fever, and four of these seven cases died. After death, two sets of ulcers 
were found in the intestines, corresponding to the two paroxysms of the fever. 
In five of the fatal cases, there was intestinal perforation; and it is worthy of 
notice, that in two only was the perforation situated in the ileum. In two cases, 
it was in the colon ; and in one, in the appendix vermiformis. In a sixth case, 
there were all the symptoms of perforation ; but the patient, a boy aged 14, re- 
covered under the use of large doses of opium. In one case, there was laryn- 



268 Progress of the Medical Sciences. [July 

gitis, causing urgent dyspnoea ; tracheotomy was performed, and the patient 
recovered. 

The treatment consisted in the frequent administration of Liebig's infusion of 
beef. No mention is made of wine. Tincture of castoreum was prescribed 
when there was impending paralysis of the lungs ; and the golden sulphuret of 
antimony when there was bronchitis, with scanty and difficult expectoration. 
Diarrhoea was treated with opiate enemata, and with tannin, rhatany, and alum, 
by the mouth. Alum, although a less powerful astringent than tannin and 
rhatany, was in most cases preferable, from its never causing vomiting. For 
intestinal hemorrhage and the symptoms of perforation, opium in large and 
repeated "doses was employed. (Zeitsch. fur Rat. Med., 3 ser., bd. v. No. 2 
and 3.) 

M. Fremy believes that he has obtained great advantage in the treatment of 
typhoid fever by rubbing in croton oil over the abdomen during the second week 
of the disease. From fifteen to thirty drops of the oil, made into an ointment, 
are to be rubbed in night and morning, until an eruption is produced. This 
application is preferable to blisters, as being devoid of the risk of gangrene. 
Of one hundred and twenty cases where this treatment was resorted to, only 
nine terminated fatally, and two of the nine patients were moribund when they 
came under observation. (Repert. de Pharm., Oct. 1860.) 

Lastly, Dr. H. Ahnes strongly recommends the administration of sulphureous 
and chalybeate mineral waters in the treatment of typhoid fevers. — British Med. 
Journ., April 6, 1861. 

17. Researches on Asphyxia; with Observations on the Effects produced 
by the Hot Bath in Asphyxiated Animals, and its Use in Restoring Suspended 
Animation. — A paper on this subject, by Dr. A. T. H. Waters, of Liverpool, 
was recently (May 14th) read before the Royal Medical and Chirurgical Society. 
Amongst the numerous researches which had been made with reference to as- 
phyxia, the author was not aware that any had been directed to one of the sub- 
jects he had investigated. Physiologists are agreed as to the order in which 
the arrest of the vital actions takes place in asphyxia, but not as to the duration 
of the heart's action, nor yet as to the best mode of treatment in suspended 
animation. The different societies, whose aim is to save life, issue rules of the 
most opposite character for the restoration of those apparently dead. Two im- 
portant points remain to be decided: first, the period after asphyxia has com- 
menced during which treatment is likely to be successful in restoring animation ; 
and, secondly, the value of the hot bath as a remedial agent. Experiments had 
been instituted by the author with reference to the following questions : 3L How 
long does the heart continue to beat in asphyxia ? 2. What are the effects of 
the hot bath on an asphyxiated animal — firstly, after all respiratory movements 
have ceased, and are not re-excited ; secondly, when respiration has been re-ex- 
cited, and is being feebly carried on ? It is difficult to decide with any degree 
of certainty with regard to the first question. Certain circumstances tend to 
throw a doubt on the generally received opinion, that " in asphyxia the move- 
ments of the heart cease in a few minutes after the cessation of the functions of 
animal life." The second question is more readily answerable, but the author 
was not aware that any experiments bearing directly on it had been performed 
previous to his own. The subjects of experiments were dogs, cats, and rabbits. 
They were drowned in water varying in temperature from 40° to 50° Fahr., and 
in one instance 36°. On being removed from the water, after every external 
symptom of life had disappeared, they were opened by the removal of the ante- 
rior part of the chest, so that the movements of the heart could be observed. 
Some of the experiments were parallel — i. e., two animals of the same age and 
size were chosen, and after being drowned in the same way, were opened at the 
same time ; the difference being that one animal was, previous to being opened, 
put into the hot bath at 100°, and the other was left exposed to the atmosphere. 
The number of animals experimented on, as just mentioned, was 28 ; of these, 
two being set aside which were submerged for an hour, in 18 the heart was found 
beating when first observed ; in 8 its action had ceased. The animals were 
opened at periods from the commencement of asphyxia varying from the fifth 



1861.] 



Medical Pathology and Therapeutics. 



269 



up to the thirteenth, and in one instance the twenty-first minute. The average 
period during which the ventricles continued to contract was nineteen minutes ; 
the longest period was in a rabbit— forty-five minutes. With regard to the first 
portion of the second question, the morbid appearances of the animals put into 
the hot bath were compared with those of the animals not so treated. In the 
animals put into the bath, the lungs were much more congested, more full of 
blood ; they were firmer in substance and specifically heavier than those not so 
treated. Both sides of the heart were loaded with blood. In some instances 
the blood was coagulated in the vessels of the lungs, the systemic veins, and the 
cavities of the heart. The blood was generally less fluid than in the animals not 
put into the bath, and coagulated more rapidly when removed from the vessels. 
In no instance did the bath produce a respiratory effort or any movement what- 
ever on the part of the animal ; it seemed further to shorten the duration of the 
heart's action. With regard to the second portion of the second question, ex- 
periments of the following character were performed : Animals were drowned 
in water from 45° to 50° Fahr. ; they were kept under water, some for one 
minute, some for one minute and a quarter, and one for two minutes. When re- 
moved from the water they were placed on the table, exposed to the air. They 
soon began to breathe feebly. In order to compare the effects of the hot bath 
with those where all treatment was omitted, some of the animals were left to 
themselves, others were put into the bath as soon as respiration had been re-ex- 
cited. Thirteen experiments were performed — twelve on rabbits, one on a cat. 
Of the thirteen, seven were put into the hot bath ; of these, six died, at periods 
varying from two to twenty hours after submersion. Six animals were left to 
themselves ; of these, four recovered and two died, both between the eighth and 
twentieth hour after submersion. The animals which had died after being put 
into the hot bath presented the following morbid appearances. The lungs were 
dark-coloured, full of blood, firm, almost liver-like in appearance. In some in- 
stances, portions sank in water ; the air-tubes were empty ; there was blood in 
all the cavities of the heart, in one instance coagulated. In the animals which 
died after submersion, but which were not put into the hot bath, the lungs were 
somewhat firm and congested, but to a less extent than in the others. The ex- 
periments appear to the author to be sufficient to establish the principle of the 
injurious influence of the hot bath, both when asphyxia is complete, and when 
recovery is commencing. In the former case, the bath momentarily increases 
the circulation ; but respiration being in abeyance, the lungs become loaded with 
blood, and the left side of the heart distended. " In the latter case, respiration 
being imperfect, engorgement of the lungs takes place, and subsequent arrest 
of the heart's action. The following conclusions are drawn by the author from 
his experiments : 1. That in asphyxia by submersion, the ventricles of the heart 
do not, as a rule, cease to contract " in a few minutes after the cessation of the 
functions of animal life," but that in many instances their action continues for a 
.very considerable period, and that this serves to explain how recovery has taken 
place after lengthened submersion. 2. That in cases of asphyxia where respi- 
ration has altogether stopped, the effects of the hot bath are : to produce an 
accumulation of blood in the lungs and in the left side of the heart, together 
with a tendency to coagulate on the part of the blood ; that it does not tend to 
prolong the action of the heart, but rather to paralyze its movements, and dimi- 
nish the duration of its contractions ; that it does not excite respiratory efforts, 
and prevents artificial respiration being properly carried out'. 3. That' in cases 
of asphyxia where respiration has been re-excited and is being feebly carried on, 
the hot bath, although in some instances it seems to have no immediate bad 
result, yet has a tendency to produce a fatal issue some hours after its use, by 
causing extreme congestion of the lungs, together with consolidation and col- 
lapse of the pulmonary tissue. The following practical inferences are drawn 
from the above conclusions : 1st. That efforts to restore animation should be 
made in all cases where asphyxia has not been of very prolonged duration. 2d. 
That the prolonged use of the hot bath in asphyxia is not only inefficacious, but 
dangerous ; and that its temporary use appears to be attended by no direct 
benefit. So far as any means similar to that of the hot bath are likely to pro- 
duce respiratory movements, the alternate dashing of hot and cold water on the 



270 Progress of the Medical Sciences. [July 

body is probably the most efficacious. 3d. That it appears safer practice to 
omit all artificial treatment, when respiration is going on feebly, than to make 
use of the hot bath. 4th. That in the treatment of asphyxia all efforts should 
be primarily directed to restoring, or continuing, the respiratory movements ; 
and all measures tending to load the lungs or embarrass the respiration should 
be avoided. The author believes that the best method of performing artificial 
respiration we are yet acquainted with is that recommended by Dr. Marshall 
H&l\.—Med. Times and Gaz., May 25, 1861. 

[At a subsequent meeting (May 28th) of the society, a letter was read 
from Sir Benjamin Bbodie, relative to the above paper. The letter referred to 
the question of the continuance of the heart's action in cases of asphyxia. Sir 
B. Brodie had never in his experiments on the subject known the rhythmical con- 
tractions of the heart to continue for more than four minutes and a half after 
complete submersion : and believed that if they had once ceased in asphyxia 
they could not be restored. Cases of recovery after a longer submersion he 
attributed to the action of the heart having previously ceased in a state of syn- 
cope. 

The late Dr. Thomas Harris, U. S. Navy, stated to us some years since, that 
he had never known an instance where a person had been actually submerged 
over five minutes, in which life had been restored.] 

18. Cerebral Circulation in Asphyxia. — Prof. Ackermann, of Eostock, has 
lately arrived at some remarkable results, from experiments made with the ob- 
ject of ascertaining the condition of the cerebral circulation in asphyxia. These 
experiments consisted in removing a portion of the skull of an animal, by means 
of a small trephine, and substituting a piece of glass. After an interval of about 
twenty-four hours, asphyxia was induced by strangulation, by submersion, by 
compression of the thorax, by injection of water into the trachea, or by some 
other plan. The condition of the brain was then watched through the glass 
plate. 

The result of these experiments is, that asphyxia was invariably found to be 
accompanied by a condition of anaemia, instead of congestion, as is generally 
believed to be the case. The anaemia was always greatest when the animal 
was asphyxiated in such a position that its head was higher than the trunk, and 
least when the animal was suspended by its lower extremities. In the former 
case, it was as pronounced as that which is observed when an animal has bled 
to death from the carotids. The congestion of the cerebral vessels, which is not 
unfrequently met with after death from asphyxia, Prof. Ackerman believes to be 
attributable to hypostatic hyperemia of a post-mortem character, favoured by 
the fluid condition of the blood, which is usually observed in asphyxia. — Brit. 
Med. Journ., 27 April, 1861, from Archives/. Path. Anat., torn. xv. 

19. Diabetes resulting from Disease of the Floor of the Fourth Ventricle. — ■ 
Two cases of diabetes are recorded in the Gaz. des Hop., for March 2d, 1861, 
where softening was found after death in the anterior wall of the fourth ventricle. 
The part of the brain which was diseased corresponded to the place of origin of 
the pneumogastric nerve ; and hence such cases, of which there are now a con- 
siderable number on record, tend to confirm the views of Professor Bernard as 
to the influence of the par vagum over the formation of sugar. — Gaz. des Hop., 
March 2, 1861. 

20. Quinine in Scarlatinal Dropsy. — Dr. Hamburger concludes a long paper 
on scarlatinal dropsy by giving his experience of the use of quinine in that 
morbid state. He has given it in forty-seven cases, in forty-four of which im- 
provement took place immediately or in a few days ; in three there was no change 
either for better or for worse. The effects observed are, diminution of the fe- 
brile symptoms of the subacute stage, increased secretion of urine, which be- 
comes clearer, reabsorption of exuded matters, even removal of already formed 
abscesses, and return of the appetite and strength. The urine, however, con- 
tinues albuminous for some time; but this does not interfere with the progress 
of convalescence. Dr. Hamburger, in summing up his observations, says that 



1861.] 



Surgery. 



271 



the action of quinine in scarlatinal dropsy is most productive of good results, 
and most rapid in the chronic stage : here improvement sets in almost imme- 
diately after the first doses. At the commencement, so long as the acute stage 
is present, the quinine may be delayed for some days, if the danger be not press- 
ing. On several occasions, Dr. Hamburger has seen the patient remain for 
several days in the same state, or even gradually become worse ; the urine be- 
coming darker and the exudations increased. But, when quinine was fearlessly 
given, a happy result followed. If marked improvement do not appear after the 
medicine has been given four or five days, it is to be omitted ; but even in this 
instance it should not be regarded as being useless, as the specificity of the disease 
appears broken by it. The dose is gr. iss to gr. ij twice a day for children ; and 
for adults gr. iij or gr. iv. During the use of the quinine, great attention must 
be paid to the diet ; especial care being taken not to overload the irritable in- 
testinal canal with slops. — British Med. Journal, May 18th, 1861, from Prag. 
Vierteljahrschrift, 1861. 

21. Two Ounces of the Wine of the Seeds of Colchicum accidentally taken by 
a Gouty Subject with Relief. — Dr. Joseph Bullar, Physician to the Eoyal 
South Hants Infirmary, records [Edinburgh Med. Journ., March, 1861) a re- 
markable case of this. 

The subject of it was a gentleman, 34 years of age, whose father and grand- 
father were gouty, and he himself, from youth, had suffered severely from fre- 
quent attacks of gout. Feeling out of order, he had taken a blue pill on going 
to bed, and intended to take black draught the next morning ; but his servant 
gave him instead two ounces of the wine of the seeds of colchicum. The mistake 
was not discovered until accidentally two hours had elapsed, when a physician 
was sent for, who considered it too late to use the stomach-pump, and expressed 
the belief that the overdose would work itself off by violent vomiting and purging, 
and advised that a dose of black draught should be at once taken, and another 
in an hour and a half. This was done, and the patient in the afternoon, while 
taking a drive, was taken with vomiting, which continued incessantly for eight 
hours. The singular points in this case are, that there was no vomiting until seven 
hours after two ounces of colchicum wine were taken, and then violent vomiting 
for eight hours, with no ill effects except nervous weakness for the next day ; but, 
on the contrary, with relief, for the last 24 years, of those severe and painful 
attacks of gout to which he had been subject for 10 years before. 



SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE 

SURGERY. 

22. Statistics of Amputation. G. F. Cooper and T. Holmes, Esq., give 
(Med. Times and Gaz., April 6, 1861) the statistics of amputations performed 
in St. George's Hospital during seven years. The total number of amputations 
is 149, and the mortality 41 or 27.6 per cent. 

There were 76 amputations of the thigh, of which 25, or 32.9 per cent., died ; 
40 of the leg, of which 13, or 32.5 per cent., died ; 22 of the arm, of which 3, 
or 13.7 per cent., died ; and 11 of the forearm, all of which recovered. 

Amputations of the Thigh. — Of the 76 amputations of the thigh, 51 are 
classed as " pathological," of which 13 (25.6 per cent.) died, and 12 as " of 
expediency," of which 5 (41.6 per cent.) died. Putting these together, we 
should have 63 cases with a mortality of 18 or 28.5 per cent. The traumatic 
amputations amount to 13, of which 7, of 53 per cent., died ; of these 9 were 
primary, of which 5 died, and 4 secondary, of which 2 died. 

Causes of Amputation and of Death. — Of the 51 cases classed as pathologi- 
cal, 8 were performed on account of abscess in the knee-joint ; of these 5 died, 
one of sloughing of the stump and phthisis, and 4 of pyaemia. 35 were for 
chronic affections of the knee ; of these 5 died — 2 of pyaemia, as proved by 



272 



Progress of the Medical Sciences. 



[July 



post-mortem examinations ; in 2 others, pyaemia was inferred from the symp- 
toms during life ; the fifth from phthisis, with sloughing of the stump. 

The 8 remaining amputations were performed for various diseases : 2 for 
malignant disease, 2 for gangrene after ligature of the femoral artery, 2 for 
necrosis, 1 for arterial hemorrhage in phagedena, and 1 for necrosis and abscess 
after excision of the knee ; of these 3 died, 1 of exhaustion, 1 of secondary 
hemorrhage, and one of pyaemia. 

Of the 12 cases classed under the head of " amputations of expediency," 9 
were on account of tumours, 2 of loss of skin after diffuse cellular inflamma- 
tion, and 1 on account of old contraction of the knee with atrophy of the leg ; 
of these 5- died — 3 of pyaemia, 1 of exhaustion, and one of secondary hemor- 
rhage. 

Of the 13 traumatic amputations, 9 were primary, and 5 of these died— 2 
from pyaemia, 2 from shock, and 1 from other injury, viz., rupture of the 
bladder ; this case should perhaps be omitted in estimating the mortality. 

Of the 4 secondary amputations of the thigh, 2 died both of pyaemia. 

So that of the 25 deaths after amputations of the thigh, we have as the 
causes : — 

Pyaemia (in two cases only inferred from the symptoms during life) 16 



Secondary hemorrhage 2 

Phthisis . . . . . . . . ....'*■, . 2 

Exhaustion . . .2 

Shock 2 

Other injury ] 



Amputations of the Leg. — The total number of amputations of the leg is 40, 
31 being for disease, viz. — 27 "pathological," and 4 "of expediency;" and 9 
traumatic, 6 primary, and 3 secondary. 

Of the "pathological," almost all were performed on account of chronic 
disease of the bones of the foot and leg ; those for acute disease of the ankle- 
joint being only 3 in number, of which 1 died. Of the remaining 24, 8 died — ■ 
4 from pyaemia, 1 from exhaustion, and 3 from the effects of strumous disease 
in remote parts of the body, the lungs, brain, and kidneys. Of the "amputa- 
tions of expediency," 2 were performed on account of painful stumps of former 
amputations (in the same limb), and 2 for tumours; all these recovered. Of 
the 9 traumatic amputations, 4 died — viz., 3 primary and 1 secondary — 2 from 
pyaemia, 1 from secondary hemorrhage, and 1 from exhaustion. 

Amputations of the Arm. — The whole number of these amputations is 22 ; 
14 for disease, of which 2 died, and 8 for accident, of which 1 died. Of the 
former class, 10 are put down as " pathological," all have been operated upon 
for disease of the bones or of the elbow-joint, where some contra-indication 
existed to excision. Of these 2 died, both of pyaemia. 4 are classed as opera- 
tions " of expediency," 3 on account of the effects of burn, and 1 (at the 
shoulder-joint) for malignant tumour of the humerus. All recovered. Of the 
traumatic amputations, 6 were primary and 2 secondary. 1 of the former died 
of pyaemia. 

Amputations of the Forearm. — These are 11 in number, and all were success- 
ful. 6 were performed on account of disease of the hand, etc., 1 (" of expedi- 
ency") for a tumour, and 4 were primary amputations. 

Comparative Mortality of the Various Classes of Amputations. — Pathological 
amputations amount on the whole to 94, of which 24, or 25.5 per cent., died ; 
amputations of expediency to 21, of which 5 died, or 23.8 per cent. ; primary 
amputations to 25, of which 9, or 36 per cent., died ; and secondary amputa- 
tions to 9, of which 3, or 33.3 per cent., died. These figures, as far as they go, 
do not bear out Mr. Bryant's statement, that " amputations of expediency" 
are much more fatal than " pathological," and secondary than primary amputa- 
tions. The list, however, is not sufficiently long to justify any very positive 
deductions. 

Comparative Mortality of Circular and Flap Operations. — Of the 149 
operations of which our table consists, 46 were flap amputations and 97 circular. 
Of the remaining 6, 3 were not noted as to this particular, and 3 cases of Syme's 



1861.] 



Surgery. 



273 



amputation are excluded. The results were as follows : Of 74 amputations of 
the thigh, 52 were circular, 15 of which died, showing a mortality of 28.8 per 
cent. ; 22 were flap, and 10 died, showing a mortality of 45.4 per cent. 

The shortest period between the operation and the patient's discharge from 
the hospital was, in the circular, 23 days, and in the flap 24 days ; the longest 
in the circular, 126, and in the flap 105 days ; the average period of cure in the 
circular 60, and in the flap 42 days. 

Of 37 amputations of the leg, 21 were circular, of which 3 died, a mortality 
of 14.2 per cent. ; 16 were flap, and 8 died, a mortality of 50 per cent. With 
respect to the period of their stay in the hospital, the shortest period was in 
the circular operations 19, and in the flap 20 days ; the longest, in the circular 
120, and in the flap 94 days ; the average, in the former 49, and in the latter 
46 days. 

It ought to be noted that, in estimating these flaps for the flap operations, 
the details of one case are excluded, in consequence of its exceptional character. 
It was that of a man who submitted to amputation of the leg twice, on account 
of irritable and painful stump. The foot had originally been removed by Syme's 
amputation at another hospital, and the leg was twice amputated at St. George's. 
On each occasion he was kept in the house a long while, on account of the 
painful and irritable condition of the integuments. It appeared unfair to 
represent the delay which this unusual state of parts occasioned as a result of 
the mode of amputating. 

Of 22 amputations of the arm, 17 were circular, of which 2 died, a mortality 
of 11.8 per cent. ; 5 were flap, of which 1 died, a mortality of 20 per cent. 
The shortest period in hospital was, in the former, 20, in the latter, 26 days ; 
the longest, in the former, 96, in the latter, 70 days ; the average of the former, 
41, of the latter, 51 days. 

Of 10 amputations of the forearm, 7 were circular and 3 flap ; none died. 
The shortest time in the hospital was, in the former class, 20, in the latter, 17 
days ; the longest, in the former, 142, in the latter, 50 ; the average of the former, 
44, of the latter, 29 days. 

This shows that out of 97 circular amputations of all kinds, 20 died, a mor- 
tality of 20.6 per cent. ; while out of 41 flap, 19 died, a mortality of 41.3 per 
cent., or just double that of the circular, and that this excess of the mortality 
of the flap over the circular prevailed in all classes of amputations. More 
extensive data are required, however, to prove beyond question that this excess 
is constant, and, if so, clinical observation must be called in to show the cause 
upon which it depends. It may be conjectured that sloughing of the flaps 
would be a frequent cause of death after the flap operation ; but our data do 
not entirely bear out this idea, nor are we prepared, at present to point out any 
decided difference in the causes of death after the two kinds of amputation. 
The list of flap amputations comprises 8 in which the flaps were formed after 
Mr. Teale's method — by the rectangular incision. In several of these cases the 
long flap sloughed, and 3 out of the 8 cases proved fatal. It should, however, 
in justice to the respected author of this operation, be remarked that some of 
. these patients were in bad health at the time of operation. The flap operation 
appears (especially in the thigh) to have some advantage in respect of rapidity 
of cure. 

Influence of Sex. — Of the 149 patients comprised in these tables, 118 were 
males, and 31 females. The mortality was 34, or 28.8 per cent., of the former, 
and 7, or 21.9 per cent., of the latter. If we remember that males are far more 
frequently the subjects of traumatic amputations, and that these are far more 
fatal than operations for disease, we shall come to the conclusion, probably, that 
females bear the operation worse than males. Of the whole number (34) of 
traumatic amputations, only 2 were performed on females. 

Influence of Age. — For the purpose of estimating the influence which age 
exerts on the mortality, the cases may be divided into four groups : those 
occurring in childhood, or below the age of 15 ; in youth, or from 15 to 25 years 
of age ; in adults, between 25 and 60 ; and in advanced life, beyond the age of 60. 

In children, below the age of 15, we find 18 operations, of which 2 died ; but 
as one of these was the result of other and necessarily fatal injuries, it would 
No. LXXXIIL— July 1861. 18 



274 



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[July 



be more correct to exclude this case, and say that of 17 operations, 1 died of 
pyaemia. 

In youth, 45 operations are recorded, of which 6 died, or 13.3 per cent. 
In adult age. 80, 31 of which died, or 38.7 per cent. 
In old age, 6, 2 of which died, or 33.3 per cent. 

Thus we see that in children amputation is ordinarily successful ; the only 
death recorded, excluding the case above referred to, was in a strumous boy on 
the limits of the prescribed age, with abscess in the knee-joint. In youth the 
proportion of deaths is far less than in adult age. In old age, there is no reason 
to conclude, that the patients, cceteris paribus, bear the operation worse than 
adults, but our figures are too small to draw any conclusions. 

The Causes of Death. — The total number of deaths was 41. The assigned 
causes of death are as follows : — 

Pyaemia in 24 cases, or 58.5 per cent. 

Exhaustion (without hemorrhage) . in 7 " or 17 " 
Exhaustion with secondary hemorrhage in 4 " or 9.7 " 
Visceral disease . . . .in 4 " or 9.7 " 
Diffuse inflammation and gangrene . in 1 " or 2.4 " 
Other injuries in 1 " or 2.4 " 

In 9 cases no post-mortem examination was made ; of these the causes assigned 
from the symptoms during life, were — pyaemia in 5 cases, exhaustion in 3, and 
secondary hemorrhage in 1. 

Thus, it will be seen that in our experience, pyaemia occupies a much larger 
space as a cause of death, than in Mr. Bryant's table: while exhaustion (without 
secondary hemorrhage) is proportionately diminished, appearing as 17 per cent, 
only, while in the Guy's Hospital records it stands for 33 per cent, of the fatal 
cases. In Mr. Bryant's paper, no mention is made of the authority on which 
his statements rest ; whether all or what proportion were examined after death, 
whether the cases produced include all the operations during a certain period, 
and if so, what period, with other interesting particulars. Thus, in this instance, 
it would require very strong evidence to convince us that one out of every three 
fatal cases of well-selected amputations died of mere exhaustion. 

If we separate the amputations, on Mr. Bryant's plan, into " pathological," 
" amputations of expediency," " primary," and " secondary," we find the causes 
of death in each class as follows : — 

Of 94 " pathological amputations," 24 died, the causes of death being — 

Pyaemia 14 or 58.3 per cent, of the fatal cases. 

Exhaustion 3 or 12.5 " 

Secondary hemorrhage . . . 2 or 8.3 " " 
Visceral disease . . . . 4 or 16.6 " " 
Gangrene from diffuse inflammation 1 or 4.2 " " 

Of 21 " amputations of expediency," 5 died — 3 of pyaemia, or 60 per cent. ; 
1 of exhaustion, or 20 per cent. ; and 1 of secondary hemorrhage, or 20 per 
cent, of the fatal cases. 

Of 25 primary amputations, 9 died — 5 of pyaemia, 55.5 per cent. ; 1 of 
secondary hemorrhage, or 11.1 per cent. ; 2 of shock, or 22.2 per cent, ; and 1 
of other injuries, or 11.1 per cent. 

Of 9 secondary amputations, 3 died — 2 of pyaemia, or 66.6 per cent. ; and 1 
of exhaustion, or 33.3 per cent. 

23. Excision of the Tendons in Amputation of the Forearm at the Lower 
Third. — Mr. Hugh Croskery communicated to the Surgical Society of Ire- 
land (April 13, 1861) the following interesting observations on this subject. 

The thousand dangers that have, in times past, been mentioned as being 
likely to occur after flap amputations at the lower third of the forearm, still 
continue to influence many surgeons of eminence to discard this operation 
altogether ; and many limbs are now removed near the elbow, where a useful 
member might have been saved. This subject is still, unhappily, a matter of 
controversy, and the probability of the occurrence of the untoward results 



1861.] 



Surgery. 



2T5 



which actuated Larrey and others to prefer the removal of the limb at the 
upper third, is still found to be a stumbling-block to conservative surgery, and 
to influence many of the surgeons of our public institutions to sacrifice large 
portions of healthy tissue. 

I communicated, in the beginning of 1859, a short paper on this subject to 
the Surgical Society, in which I described "a case of amputation of the right 
forearm at the lower third, in which the tendons were drawn down and divided 
an inch above their termination in the flaps ;" and I brought forward that case, 
in the hope that the great success which followed the plan adopted would induce 
others to make further trial of it, and to communicate the results of their ex- 
perience of it to the profession. I performed this operation, for the first time, 
in October, 1858, and a short time after I had communicated it to the Surgical 
Society, Mr. Alford, surgeon to the Taunton and Somerset Hospital, operated 
in a similar way, and published the results in the Medical Times and Gazette 
of Feb. 4th, 1860. In both these cases a useful limb was preserved, and the 
stump healed in a very short space of time. The subject of my case has been 
my own servant for the past three years, and he can use his handless forearm 
with wonderful facility. 

I have lately had further opportunity for testing the value of this mode of 
amputation, and I have now no hesitation in strongly recommending its general 
adoption. It is easily performed. Two flaps are made after the process of 
Yermale — the palmer by transfixion, and the dorsal by cutting in a semicircular 
course from the tegumentary surface, the flap being then dissected back. After 
the limb has been separated in the usual way and the arteries have been tied, 
the soft parts are drawn well back by an assistant, when the tendons will pro- 
trude. Each tendon is then grasped with the rasped blades of a spring-forceps, 
drawn out, and cut off on a level with the flap. The flaps, which should be two 
inches in length, of equal size, and with broad angles, are then brought toge- 
ther with sutures and adhesive straps, and a roller is carefully and evenly 
applied with the view to the obliteration of the cavities left by the retraction 
of the tendons. The bandage should be brought up as far as the edges of the 
flaps, and the face of the stump should not be covered by it, but merely dressed 
with wetted lint. The flaps will be found to adapt themselves accurately to- 
gether; and to furnish all that is requisite for immediate union. The stump 
will be healed completely within three weeks, and the bones will be protected 
by a firm cellulo-integumentary cushion. 

The advantages of this operation are very great, and I do hope that other 
surgeons will give it a trial, and that it will be found to be as successful in their 
hands as it has been in mine. I have been, I believe, the first to bring it to the 
notice of the profession, if I have not been the first to practice it; and in bring- 
ing it to the notice of such a learned body as the Surgical Society of Ireland, 
my object is to have its merits, or demerits, discussed by a competent tribunal. 
I have found it to succeed in my own practice, and I am confident of its success 
in other and more skilful hands than mine. — Dublin Medical Press, May 1st, 
1861. 

24. Extirpation of the Shaft of the Tibia. Complete Recovery. — The sub- 
ject of this operation was a young man who had been affected with necrosis of 
the tibia for two years, and whose leg was, consequently, in such a disorganized 
condition that some of the most eminent Parisian surgeons, amongst whom it 
will suffice to mention M. Yelpeau, had pronounced amputation at the thigh to 
be necessary. The performance of sub-periosteal extirpation of the substance 
of the tibia saved this patient, however, from the alternative of an operation 
which, according to French statistics, results in death in sixty per cent, of the 
cases in which it is resorted to, and has restored the limb to almost its original 
integrity of form, flexibility, and strength. 

The portion of bone removed by M. Maisonneuve, under whose care the pa- 
tient had been placed, was more than twelve inches long, an inch and a half in 
diameter at its upper end, and an inch at its lower extremity. Its surfaces were 
smooth and compact inferiorly, roughened and hollowed out superiorly. 

The sequelae of this operation were remarkable for their simplicity. The 



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[July 



traumatic fever was of a very moderate character ; the suppuration, which had 
previously been abundant and fetid, was replaced by a free discharge of a healthy 
character ; and after the fortieth day the patient was able to get up and walk 
about with the aid of crutches, in the same manner as if a simple fracture only 
had been under treatment. The bone was very completely reproduced, and 
when M. Maisonneuve reported upon this case at the meeting of the Academy 
of Sciences, on the 18th of March, the young man had become strong and 
vigorous, the limb, which was formerly the seat of disease, not differing in any 
way from the other. 

The value of the preservation of the periosteum with a view to saving the 
limb by thus promoting the formation of new bone has recently engrossed much 
professional attention in France. The Academy of Sciences have offered a 
prize of £200 for the best essay upon this subject, to be sent in early in 1862, 
and the Emperor, having learnt the importance which would attach to a proper 
solution of this question, has expressed his intention to double the prize. — Lond. 
Med, Rev., May, 1861. 

25. On the Growth of Long Bones and of Stumps. — Dr. Humphrey read some 
interesting observations on these subjects before the Royal Medical and Chi- 
rurgical Society, April 12, 1861. In the first part of his paper he gave the re- 
sults of some experiments with madder upon the bones of pigs with reference to 
the mode of growth of the bones in length. They were confirmatory of the ob- 
servations by Hales, Duhamel, Hunter, and others, that the elongation is effected 
by addition at the ends of the shafts, the addition being effected by growth and 
ossification of the epiphysial strata of cartilage on the side next to the shaft. 
The experiments further showed that the growth at the two ends of the shaft is 
unequal ; that it is usually most rapid at the larger end of the bone ; and that it 
is always most rapid at the end where the epiphysial cartilage remains latest — 
that is to say, the growth proceeds most rapidly at the end where it is longest 
continued. The proper relation of the soft parts to the bone during the periods 
of growth is maintained by the interstitial growth of the periosteum, and by the 
continual sliding or shifting of that membrane upon the bone towards the end at 
which the growth is most rapid. This is attended with a certain traction upon 
the medullary and other vessels, and determines the direction of the canal for 
the medullary artery, which is always slanted towards that epiphysis which is 
last ossified to the shaft ; in other words, towards that epiphysial line in which 
growth proceeds most quickly. The amount of growth in the respective epi- 
physial lines is very determined, and corresponds exactly on the two sides of the 
body, though that on the one side is not affected by the other ; and it appers to 
regulate the amount of growth of the soft parts ; for, if it be either arrested or 
accelerated, the growth of the soft parts is affected in a similar manner. In the 
second part of the paper the author showed the common impression, that a 
stump keeps pace with the rest of the body in its growth, to be erroneous. He 
did this by measurements taken from persons who had undergone amputation in 
childhood, and by experiments upon animals. The rate of growth varies. The 
stump rarely maintains its relation to the corresponding segment of the other 
limb ; and it fails to do so, as might be expected, most markedly in those parts 
in which the growth of the bone takes place chiefly at the lower end. Thus, if 
amputation in the thigh be performed on a young child, one-third from the lower 
end, the stump, when full growth has been attained, will not be more than a 
third as long as the other thigh ; its relative length will have thus been altered 
from two-thirds to one-third — that is, it will not have grown more than half as 
fast as the other thigh. The information derived from the measurements of 
stumps was thus shown to be quite corroborative of the observations made, in 
the first part of the paper, respecting the growth of the bones at their epiphysial 
lines. The instances in which the bone of a stump elongates so as to be trou- 
blesome and require a portion to be removed, are regarded by the author as 
quite exceptional, the phenomenon being probably due to some irritation, and 
being, therefore, of the same nature as the spicules and exostoses which are oc- 
casionally found upon stumps and on other parts of the skeleton. — Med. Times 
and Gazette, April 20th, 1861. 



1861.2 



Surgery. 



26. Mode of Union of Fractures. — Mr. Lawson exhibited (April 8th, 1861), 
to the Medical Society of London, two specimens illustrative of this, in which, 
under opposite circumstances, two distinctly different processes had taken place. 

The first was that of the femur of an infant, nine months old, which had been 
broken, and in which the repair had been accomplished through the medium of 
a circumferential callus. The fracture had not been discovered until some weeks 
after the accident, consequently the extremities of the bones had not been kept 
in a state of perfect rest, and reparation had been effected in a manner similar 
to that which takes place in the repair of fractures of the long bones of animals. 

The second specimen was the lower end of the femur, taken from a man who 
had met with a compound and comminuted fracture of that bone at the junction 
of its middle and lower third, and in which a vertical split, passing into the joint, 
had completely separated the two condyles. The man had progressed at first 
satisfactorily; but acute necrosis of the upper extremity of the femur obliged him 
(Mr, Lawson) to amputate the thigh, in its upper third, three months after the 
injury. The patient is now convalescent. In this preparation the two condyles, 
which had been entirely separated by a vertical split, had united ; and from 
having been maintained in a state of perfect rest, and in direct apposition, the 
union had been effected without the intervention of any callus. 

27. Removal of a Ball by means of the Trephine Twenty-two Months after 
its Penetration into the Cranium. By M. Jobeet. — J. G., aged 21, was admitted 
into the Hotel-Dieu, Feb. 10th, 1857. Forming one of a force posted in front 
of the Malakoff tower, 8th April, 1855, he was struck by a ball in the forehead, 
the projectile, prior to penetrating the cranium, having come in contact wi^i 
the external surface of the vizor, leaving a semilunar depression as it passed 
over the external edge of this. The man immediately fell from the parapet 
into the trench, a depth of seven feet, and remained unconscious in the ambu- 
lance for twenty-four hours. At the end of a week he was sent to the military 
hospital at Constantinople, where he stayed during four months. He then re- 
quested permission to return to the Crimea, and did so, in spite of the suppura- 
tion, which had never ceased. He fought at Traktir, 16th August, 1855, and 
returning to Paris in December, he remained for six months longer in the regi- 
ment. He was, however, unfitted for active service, being obliged to pass a 
considerable time in hospital. The symptoms continued much the same from 
the first, and consisted in a sensation of heaviness of the head, an uncertainty 
in the attitudes, and a feeling, when stooping, as if the forehead were separating 
from the head, suppuration always persisting. 

On his admission into the Hotel Dieu, a clean, circular aperture, about the 
size of a franc, was observed in the centre of the forehead. Passing the finger 
around the circumference of the opening, "osseous granulations, partial ossifi- 
cations formed by the periosteum," could be felt, and on the introduction of a 
probe to the bottom, a hard, resisting, metallic body was recognized. After a 
crucial incision had been made and the aperture caused by the ball was found 
not to be sufficiently large to admit of its extraction, a circle of bone was 
removed by means of the trephine. The ball was now extracted, and some 
indurated, blackish blood was removed. The movements of elevation and de- 
pression of the dura mater, isochronous with the pulse, were plainly perceptible. 
The projectile proved to be a leaden ball weighing twenty-five grammes (375 
grains.) Its surface was smooth and spherical over only a small portion of its 
extent, the remainder being rough and irregular. The details of the recovery 
need not be pursued, it sufficing to say that this was complete, the man as late 
as October, 1860, having been seen perfectlv well. 

M. Jobert calls attention to the fact of the ball having remained for so long 
a period in contact with the dura- mater without inducing any inflammatory ac- 
tion. He also lays stress upon the circumstance of his having, after the com- 
pletion of the operation, introduced the flaps formed by the crucial incision 
into the accidental opening. To this he attributes the non-occurrence of necro- 
sis or osseous exfoliation usually observed after trephine operations when the 
parts are exposed to the air. Here, such exposure was prevented, immediate 
union of the raw flaps with the bleeding osseous surface being secured. The 



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Progress op the -Medical Sciences. 



[July 



isochronous pulsations continued for a time visible, but they became more and 
more obscure as the tissues covering the aperture augmented in thickness. — 
Brit. §• For. Med.-Chir. Rev., Ap. 1861, from Comptes Rendus, 1861, No. 6. 

28. Gunshot Wounds produced during the Loading of Artillery. — Dr. Cortese 
relates five cases of gunshot wounds received by artillerymen while engaged in 
loading their guns, and gives the following summary of his observation : 1. No 
other blow of a projectile imparts like the present so great an amount of com- 
motion to the entire limb. The state of muscular contraction prevailing at the 
time constitutes a kind of solidarity between the hand, forearm, and arm, 
which is the chief and necessary cause of this commotion. 2. This circum- 
stance compels the surgeon to direct his attention to the entire limb, whatever 
amount of lesion may be manifest in the hand. A neglect of this precept may 
lead to gangrene gaining possession of a large portion of the limb, or to a gene- 
ralized suppuration, while a diminished power of reaction in the injured parts 
may give rise to purulent infection, or render useless recourse to amputation. 

3. In all those cases in which the hand is severely torn, its disarticulation, or 
even the amputation of the forearm, is insufficient to secure recovery. The sur- 
geon's knife penetrates into infiltrated tissues, more or less destroyed in their 
intimate structure in consequence of the concussion they have been subjected 
to. So that independently of the fracture of the bone, and of the possible dis- 
junction of the articulations of the ulna, the success of the reparative process 
would be very problematical. In such cases the arm should be amputated. 

4. The sooner amputation is performed, the greater is the probability of a 
favourable result. 5. The rapid and very extensive tumefaction of the limb 
constitutes a sufficiently certain criterion of the severity of the derangements 
which are propagated along its whole extent. When fractures are not detected 
in the diaphysis of the bone, some lesion of contiguity or continuity in the 
ulnar articulation must be suspected. 6. When the lesion does not seem severe 
enough to call at once for amputation, we must always be prepared for secon- 
dary occurrences which will unfit the limb for its functions. (In two of the 
author's cases, paralysis of the limb remained.) Still, conservative treatment 
in such cases should be attempted. — Brit. For. Med.-Chirurg. Rev., April, 
1 861, from Omodei Annali Univ. di Med., vol. clxxiv. 

29. Traumatic Tetanus. — Mr. J. Hutchinson and Dr. J. H. Jackson have 
given [Med. Times and Gaz., April 6, 1861) a tabular statement of 22 cases of 
recovery from traumatic tetanus. The following are their conclusions as to the 
management of this disease. 

1. The chief objects in view are three — to mitigate the force of the local 
irritation to which the disease is due ; to sustain the patient's strength by food ; 
and, lastly, by procuring sleep, to allow the nervous system the opportunity of 
regaining its wasted powers. 

2. If the case be seen in the very onset, and if the injured part be a finger or 
toe, it is desirable at once to amputate, whatever may be the local condition. 
If the injury has been severe, and the part have passed into a state in which, 
whether from sloughing or otherwise, its recovery is doubtful, it is desirable to 
amputate at any stage of the disease, or even if one of the extremities be the 
part involved. 

3. The injured part should be poulticed, and the limb above it wrapped in lint 
soaked in laudanum or chloroform. 

4. The patient should be put in a room with but one attendant, and the strictest 
quietude should be insisted on. 

5. If the patient has been accustomed to it, he should be allowed to smoke. 

6. The bowels should be well cleared out by croton oil or other efficient pur- 
gative. 

7. If the skin be very hot, the pulse jerking, and the tongue red and dryish, 
the surgeon may be justified in combining small doses of calomel with the nar- 
cotic he may have selected for employment. 

8. A free allowance of beef-tea, milk, eggs, and similar articles of concentrated 



1861.] 



Surgery. 



219 



fluid nutriment should be given, more especially in the later stages of the com- 
plaint. 

9. As long as the patient is able to take food and to obtain periods of com- 
parative quiet and freedom from pain, the use of anaesthetic inhalations is not 
desirable. Great advantages may, however, be obtained from them if he be 
unable to open the jaw sufficiently to permit of taking food, or if the tetanic 
spasms are without remission. Ether appears to have stronger facts in its re- 
commendation than chloroform. 

10. One or other form of narcotic — opium, Indian hemp, belladonna, or 
woorara — should be freely used. There is no very decisive evidence as to 
the advantage of any one of these over the others. Eespecting the Indian 
hemp and the woorara, the difficulty often encountered in obtaining them in a 
state of reliable activity will often be an obstacle to their employment. 

11. Excepting possibly in the per-acute cases the free use of quinine appears 
to be desirable. If given in large closes it generally reduces the frequency of 
the pulse, and in some cases a mitigation of the tendency to spasm has attended 
its influence. The rapid induction of cinchonism is a measure well worthy of a 
fair trial. 

30. Radical Cure of Reducible Hernia. — Professor Stme exhibited a patient 
to the Medico-Chirurgical Society of Edinburgh who had suffered from reducible 
inguinal hernia, and on whom he had lately operated by a method which accom- 
plished the object aimed at by TTiitzers operation, by a simpler mode, and one 
which he believed to be more effectual. 

By the method recommended by Prof. S., "instead of a complicated apparatus 
for filling up the inguinal canal, the surgeon only required an elongated body of 
some kind, such as a piece of bougie, a piece of an oesophagus tube, a bit of 
wood, or even part of a wax or tallow candle ; all the preparation required was. 
that a hole should be drilled through one end of the body chosen. The remain- 
ing apparatus consisted of a piece of strong thread and a needle, such as is used 
in sewing up dead bodies. The mode of application was as follows : The string 
was passed through the hole in the end of the body; the needle was threaded 
with one end of the string, and laid with its concavity resting on the forefinger 
of the left hand, which was then passed up along the cord within the external 
ring ; the needle was then turned round, so as to bring its point upwards, and 
passed, with an inclination to the left, through the textures, and brought out 
on the surface of the abdomen ; the other end of the thread was then passed 
through the parietes in the same way, only that this time the inclination of the 
needle was to the right ; the two threads were then pulled tight enough to draw 
the body up the canal, and up it must go. The piece of tube, as in Mr. Wiitzer's 
operation, was smeared with cantharides ointment, to irritate the skin and favour 
the formation of adhesions. The two ends of the thread were then tied together ; 
and. to prevent any chance of cutting through the skin too fast, a bit of elastic 
bougie was placed below them. For three or four days, or a week, a compress 
was placed over the groin, and retained in position by a bandage ; and this was 
the whole process." 

Prof. S. stated that he had repeatedly operated by this method, and in no case 
with any bad effect. — Edinburgh Jled.Journ., April, 1861. 

31. Abdominal or Pelvic Abscess. — F. C. Skey, Esq., makes some interesting 
remarks on this disease (Lancet, April 27th, 1861). "These abscesses," he 
observes, k< commonly present themselves in persons of impaired constitutions, 
reduced whether by accidental illness, by low living, or by any other debilitating 
cause. So far as I have seen and observed them, and I have attended many, 
their formation is always the result of one of these, or similar causes. There is, 
however, in this circumstance nothing very strange or remarkable, because, 
probably, all abscesses on a large scale are the product of low, and not of an 
exalted vitality. 

' ; The general situation of that variety which forms the subject of my present 
remarks is the iliac fossa. It may, therefore, be termed either ' abdominal' or 
' pelvic ;' for although it occupies the iliac fossa, it is placed within the general 



280 



Progress of the Medical Sciences. [July 



walls of the abdomen. It appears in the form of a firm, not necessarily a hard, 
swelling, very distinctly perceptible on pressure over the above region. If small 
its presence is only readily detectable by comparison with the opposite fossa, 
into which the ends of the fingers sink on moderate pressure. In this respect, 
however, there is a difference appertaining to the varieties in the form and quantity 
of the contents contained within the abdominal walls, especially of fat, and the 
greater or less laxity of the walls themselves. Occurring in young women 
shortly after parturition, its presence is remarkably distinct. When large, the 
swelling is apparent to the eye as well as the touch, and it extends across 
the abdomen towards the mesial line, and upwards in the direction of the um- 
bilicus. In such cases the swelling is prominent, and as it increases in magni- 
tude, it encroaches on the intestines, which are pushed across to the opposite 
side. In many cases pain is not a prominent feature, and when present, it is 
usually not severe, but is dull and aching rather than acute in character. 

" In its early stage I have known this form of disease to be mistaken for two 
other varieties of swelling — malignant disease of the pelvis, and scybalaB in the 
colon. From malignant disease it may be distinguished by the general uniformity 
of the swelling, and by the less serious constitutional signs of health undermined ; 
and judging from liabilities, malignant growths of or from the pelvis are far more 
uncommon than chronic abscesses. These examples of pelvic abscess have pre- 
sented themselves to my observation more commonly on the right than on the 
left side. I am not aware whether scybalse collect more usually on that than on 
the left ; but certainly they are more palpable and more readily detectable in the 
head of the colon than in the descending part of the intestine, which is placed in 
less proximity to the abdominal walls than that on the right side. But scybalse 
are limited in their relation to the front abdominal walls by the caput coli, and 
moreover are movable, whereas the mass, which gradually resolves itself into 
the abscess, presents to the hand the sensation of a large and solid deposit, 
firmly fixed, and considerably larger than the intestine itself. The disease pro- 
gresses very slowly, and often requires weeks for its development. As a general 
rule, it becomes soft, or, in other words, is converted into an abscess, which oc- 
cupies its original site ; in other cases the sac yields, and the matter extends in 
one or more directions, of which the most common is downwards along the track 
of the femoral vessels. I have seen three examples in which the matter made 
its way backwards through the sacro-ischiatic foramen, presenting the dimensions 
of a formidable abscess on the buttock, the upper part of the thigh, or over the 
region of the trochanter major. Occasionally the matter will extend across the 
abdomen behind the peritoneum, and take the course of the vessels of the oppo- 
site side, where it may point through the abdominal muscles above Poupart's 
ligament. In the case of a lady to which my attention was recently called, a 
large collection of matter formed underneath the integuments of the right iliac 
region. The abscess had been preceded by a large mass occupying the fossa 
beneath it for the period of many weeks. After having evacuated the sac. I 
detected an opening through the aponeurosis of the external oblique muscle 
sufficiently large to admit the end of the forefinger, through which the matter 
had escaped from the abscess below. The outer cyst contained about a pint of 
brownish pus, both in colour and consistence very unlike the fluid contained in 
a psoas abscess. 

" Two remarkable examples of this disease have been under my treatment in 
St. Bartholomew's Hospital within the last few months. The first was that of 
a boy about fifteen years of age, who fell down on the ice in J anuary last, and 
struck his left trochanter severely. Considerable pain followed the injury, which 
was deemed rheumatic ; and he was admitted into the above hospital and placed 
in a medical ward. While there, a swelling formed over the right iliac fossa, 
for which he was removed into a surgical ward, and came under my care. He 
had an abscess pointing both above and below Poupart's ligament. The upper 
projection was very prominent, and threatening shortly to burst its way through 
the skin ; but I preferred to evacuate the abscess through the lower opening. 
About six or eight ounces of matter escaped. For some days he appeared 
much relieved by the operation ; but he gradually lost his appetite, became 
hectic, and died in three weeks. On examination, it was discovered that the 



1861.] 



Surgery. 



281 



fall had occasioned a rapture of the fibrous capsule of the left hip-joint, and 
fracture of the acetabulum. Matter had formed in this region, which had ex- 
tended across the abdomen behind the peritoneum to the right side, and made 
its way through the abdominal parietes where I had punctured it. During life 
the boy did not complain of any pain or even discomfort on the left side ; and 
what is worthy of remark is, that during the last week of his life he lay over 
entirely on his left hip. 

" When these pelvic abscesses are large and their progress towards maturity 
is unusually slow, when they are placed deeply within the pelvis and the matter 
is bound down by the pelvic fascia, they seldom fail to involve contiguous bone ; 
in which case they generally prove fatal. I opened a large abscess occupying 
the left iliac fossa of a lady thirty years of age. I had watched the progress of 
the disease for many weeks. She died, and on examination the matter was 
found to have involved the entire surface of the venter ilii. 

" The indication to which the treatment in such cases clearly points is that 
which will most readily convert a chronic into an acute abscess. Any attempt 
to ' resolve' or ' discuss' these morbid deposits would be futile, and quite un- 
worthy the advanced progress of scientific surgery. To what end would mer- 
curial ointment and iodine and similar agents point ? What is their power ? 
Do they possess any ? And if they do, could mercurial inunctions induce the 
circulating system to reverse its action by taking up the morbid deposit it had 
previously got rid of? In large chronic abscess, whether in the primary 
thickening or the confirmed stage of fluidity, every function of the body is 
stamped with indications of debility. Can we hope to infuse healthy actions 
and promote vital power in a part while the whole remainder continues weak ? 
The condition is that of weakness. Why matter or lymph was deposited 
in this or that locality it may not be easy to solve, but we can readily conceive 
that if not deposited there the morbid condition would present itself elsewhere 
in the system. In order to obtain absorption of the deposited mass without 
passing into suppuration we must convert the present stage of debility into the 
highest condition of vigorous health, and that is impossible. All that we can 
hope for, all that the best resources of art can achieve, is to change the chronic 
into an acute abscess, to advance the formation of pus, and to compel the abscess 
to select that locality through which it can most readily discharge its contents 
on a surface of the body. To effect this the appetite must be improved, and 
gratified with as large a quantity of nutritious food as can be digested; force 
and vigour must be given to the pulse by means of stimulants — and the capacity 
for stimulants in these cases of debility is very great — while the lungs should 
be supplied with an ample quantity of fresh air for the thorough oxygenation of 
the blood. 

" If there be one therapeutic agent more valuable than another in promoting 
suppurative action, it is bark, and it should be given throughout the treatment 
in full quantities. At the earliest moment at which fluid can be detected near 
the surface the abscess should be freely opened. It most commonly points 
through the abdominal muscles, but the rule equally applies should the abscess 
point towards the rectum, or, when occurring in the female, towards the vagina, 
or on the nates or region of the trochanter." 

32. Pulsating Bronchocele. — Dr. J. Bullar read before the Royal Medical 
and Chirurgical Society (Feb. 26, 1861) an account of two cases of bronchocele, 
in which the distinctive complication was the violent pulsation of the carotid 
arteries and of the enlarged thyroid arteries, communicating the pulsation and 
thrill to every part of the enlarged lobes. In one of these (a male), the pulsa- 
tion and bruit were so communicated to the lobes, the enlargement of which 
was of small size, that the case had been suspected to be carotid aneurism, and 
it required careful examination to be certain of its exact nature. It was brought 
on by pressure, round the neck, of tight shirt-collars, the patient being in a state 
of great debility. Under a tonic regimen, with quinine, iron, iodide of potas- 
sium, in small doses internally, and iodine externally, the pulsation gradually 
ceased, so that twelve months afterwards the only vestige was a small hardness 
of one lobe. In the second case (a female), the bronchocele was much larger, 



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[July 



the pulsation even more pronounced, and with great distension of the veins of 
the neck. This was combined with disease of the heart, ascites, and anasarca 
of the legs. Under diuretics (including digitalis and iodide of potassium) and 
iron, the dropsical symptoms were removed, and at the same time the pulsation 
and venous distension ceased, and she was restored in five months to compara- 
tive health. Iodine externally somewhat diminished the bronchocele. Sir Ben- 
jamin Brodie, who saw the first case, in a letter given, states that he has only 
seen one other. In both cases, that undue prominence of the eyeballs which 
often attends bronchocele in the anaemic, was well-marked, and remained, though 
diminished. 

Dr. Edward Smith was not aware that the cases were so rare as the author 
supposed.. He had seen one case. The subject of it was a lady, aged 20. It 
was well-marked, and the bronchocele pulsated strongly, and varied both in size 
and in degree of pulsation at different times. There was in this case, also, dis- 
turbance of the uterine functions. — Med. Times and Gaz., March 9, 1861. 

33. Communication of Secondary Syphilis. — The following case, communi- 
cated to the British Medical Journal (March 23, 1861), illustrates some inte- 
resting points concerning the transmission of secondary syphilis. It shows, in 
particular, that a chancre once healed may, nevertheless, during the progress of 
the constitutional disease, yield a secretion which (although not capable of being 
again inoculated upon the same patient) may infect others, and produce in them 
a disease having all the characters of the primary indurated chancre : — 

" Two years ago a lady consulted me for what she described as a complete 
break-up in her health, and as I had known her before, the change in her ap- 
pearance was certainly very remarkable. She had been a widow, but had mar- 
ried some months before a gentleman much younger than herself, and, after 
some questioning, I discovered, at last, something that excited my suspicions. 
On making an examination, I found inside the labia two indurated chancres im- 
mediately behind the fourchette. They were too well-marked to allow the 
slightest doubt to exist about their nature ; and, on inquiry, I found she had 
first noticed them about six or seven weeks before ; one of the glands in the 
groin was likewise materially enlarged. Before putting her under treatment, I 
saw her husband, and he at once informed me that nearly a year before his mar- 
riage he had contracted a sore, had been treated by an apothecary, and had been 
pronounced quite well. He had never any eruption on his skin, but had since 
laboured under ulcerated sore-throat and pains in his joints, which he attributed 
to rheumatism. I examined his penis, and between the prepuce and the glands 
on one side of the mesial line was the remains of a large ulcer, hard and irregu- 
lar ; but apparently quite healed, though I thought I could detect a slight watery 
exudation from its surface. Perfectly satisfied now in my own mind as to the 
nature of the affection his wife was labouring under, I put her at once under the 
influence of mercury, and with the usual local treatment the sores on the genitals 
healed, and the tumour in the groin disappeared. Some months afterwards, 
however, her chest and back were covered with a copper-coloured eruption ; the 
glands in her neck likewise became engaged, and a deep ulcer appeared on one 
of her tonsils. Under suitable treatment, she has perfectly recovered, and her 
health has continued good up to the present time. Her husband, who, I think, 
was not at first thoroughly satisfied as to the fact that he was the cause of his 
wife's illness, -was shortly afterwards made painfully aware of its truth. He was 
attacked with syphilitic laryngitis, and his life was saved almost by a miracle. A 
large venereal bubo likewise formed in his groin, involving a degree of suffering 
that was absolutely pitiable." 

34. On Affection of the Mucous Follicles of the Urethra in Gonorrhoea. By 
M. Diday. — If we examine closely the orifice of the urethra in a subject of gonor- 
rhoea, we may sometimes discover in its vicinity a narrow aperture, through 
which may be made to issue, by pressing the glans forward, a droplet of dis- 
charge. Passing a needle into this aperture, it penetrates to a depth of from 
three to six millimetres in a direction parallel with the urethra. The orifice of 
this aperture resembles that of the urethra in being red, tumefied, pale, or indo- 



1861.] 



Ophthalmology. 



283 



lent, accordingly as the gonorrhoea is in its acute or chronic stage ; and when the 
patient has gonorrhoea several times, this lesion will be found always reproduced. 
The lesion consists in the gonorrhceal condition of one of the mucous follicles 
of the urethra, and constitutes a highly troublesome complication of the ordi- 
nary urethral affection, as respects the curability of this latter and the prolonga- 
tion of contagiosity. The contagious pus which issues from the follicle is small 
in quantity and intermittent in appearance, and the lesion may be easily over- 
looked. Unaffected by injections and balsamiferous urine which do not come 
in contact with it, this lesion may persist long after that of the urethra has been 
cured, and as long as it does persist, infection continues. After trying various 
means for its cure, M. Diday has come to the conclusion that the only one which 
is feasible is the obliteration of the abnormal cavity by means of the actual 
cautery. He at first effected this by introducing a small heated needle into the 
orifice, and carrying it to the end of the passage ; but as the doing this is some- 
what tedious, the needle had time to cool before reaching its destination. The 
plan he has finally arrived at, and the one which he recommends as quite suc- 
cessful, is to pass a small knitting-needle to the very bottom of the duct, and 
shielding the glans by means of a paper covering, to heat the needle by placing 
a candle under it until the orifice is whitened, and a grizzling sound is beard. 
This amount of cauterization suffices for the cure, and when performed thus 
slowly, is easily effected. All acute inflammatory action must have subsided 
before it is put into force. 

M. Diday takes occasion to observe, that in gonorrhoea the inflammation 
does not occupy the surface of the canal, but is engaged with a number of folli- 
cles similar to the one mentioned above, and that our object in its treatment 
should be to retain medicinal agents in the urethra as long as possible, so that 
they may penetrate into these little recesses. This may be done, in the case 
of urine charged with copaiba or cubebs, by means of a forceps contrived by 
M. Diday, the urine being thus kept for several hours in contact with the parts. 
When injections are employed, too, pressure should be made by the fingers at 
the entrance of the urethra and behind the scrotum, the fluid thus, imprisoned 
being then forced to and fro. — Brit, For. Med.-Chirurg. Rev., April, 1861, 
from Gazette Hebdomadaire, 1860, No. 45. 



OPHTHALMOLOGY. 

35. Impairments of Vision caused by Lactation. —Mr. Geo. Lawson has 
published [London Med. Rev., May, 1861) some interesting remarks on the 
impairments of vision so common in feeble women, or those labouring under 
exhaustion, during the period of lactation. Mr. L. points out two distinct 
forms of the disease. " In the one the eye is directly affected, and there is suf- 
ficient manifestation of morbid action to account for all the impairment of vision 
of which the patient complains. In the other the defect appears to be central 
or cerebral. The appearance of the eye is normal, or the conjunctiva may look, 
perhaps, more pale or blue than usual, corresponding with the anaemic condition 
of the patient, or sometimes it may be even a little injected, but there is nothing 
to be seen either externally or with the ophthalmoscope to account for the defi- 
ciency of sight from which she suffers. 

"In the first form the symptoms are as follows : The patient complains of her 
eye being bloodshot ; a feeling of giddiness ; and of some slight intolerance of 
light. There is an inability to read long, as the lines become misty and the words 
run together ; the eye looks inflamed, irritable, and watery, presenting very much 
the appearance of one from which a foreign body, as a bit of dust, or a spicula 
of iron, had been lately removed. It has a generally pink appearance, and the 
ciliary veins are rather large, showing internal congestion. If the case be a 
severe one, the redness increases, as does also the impairment of vision, until she 
is able scarcely to read large cannon type ; the pupils are sluggish and rather 



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[July 



contracted ; her pulse quick and small ; and her appearance that of exhaustion, 
accompanied with some febrile symptoms. Her sleep is disturbed ; and on 
rising in the morning she has a feeling of giddiness and lassitude as if she had 
never been to bed. The appetite is bad. 

" The case is one of choroidal congestion, and this congestion is passive. It is 
dependent on anaemia, and on an exhausted condition of the nervous system 
produced by suckling. The delicate vessels of the choroid, furnished as they 
are with filaments from the sympathetic nerve, are capable in health of main- 
taining their proper calibre during the circulation of the blood in them ; but 
when the patient has become exhausted by long suckling, and exhausted to an 
extent which no other cause seems capable of producing, these vessels seem to 
lose the control of their sympathetic filaments, and to yield before the impulse 
of the blood, and thus become distended. Choroidal congestion is produced, 
and its effects are soon realized. That this congestion is the result of a defi- 
cient sympathetic nervous supply is clear from the experience of Brown-Sequard, 
who divided in a rabbit the sympathetic nerve in the neck, and immediately pro- 
duced a turgescence of all the parts above the seat of the division, the side of 
the head and face in which the division was effected becoming visibly congested, 
and its temperature sensibly increased. 

" If the case be now properly treated there is every probability of the eye 
being soon restored to its normal state ; but if the patient continues to nurse 
and to neglect all those remedies which are placed at her disposal the disease 
progresses, the iris becomes involved, and a low form of choroido-iritis or cho- 
roido-retinitis is the result. Plastic effusions may now take place, and perma- 
nent mischief may follow, such as adhesions between the iris and lens, or effusion 
between the choroid and retina." 

In the second form, there is "in the early stage, nothing whatever to be seen 
on looking at the eye superficially, beyond the pallor of the conjunctiva, which, 
however, corresponds with the anaemic look of the patient. Frequently there is 
a little conjunctivitis, associated with a red condition of the edges of the lids 
and caruncle, appearances which are characteristic of want of power. It is this 
impairment of vision which is most generally seen in its slightest forms, and for 
which the surgeon is so frequently consulted. Giddiness and lassitude on rising 
in the morning, and a failing of the appetite, with general muscular debility, are 
the early symptoms which indicate that the drain produced by lactation is 
greater than the patient makes up for by the nourishment she takes. 

" Eeading is difficult, and is attended with an effort, but the words soon become 
confused, and the lines run together, and the book or paper is obliged to be 
thrown away. 

" Similar symptoms are described by the poorer classes in reference to their 
work; they lose the stitches, and cannot see where they last entered the needle. 

" These symptoms are so common, that they must have been observed by all, 
and frequently an improved diet, with tonics and other means which are used for 
the improvement of the health, may enable the patient to continue nursing her 
child, and at the same time to afford relief to the symptoms she is suffering from. 
The condition of sight of the patient at this period, may be described as that of 
asthenopia. Debilitated by an exhausting cause, her nervous energy is en- 
feebled, and the general muscular debility which exists in such cases is strikingly 
shown in the want of power which prevents the patient maintaining the action 
of the ciliary muscle for accommodating the eye to near objects, and thus 
converging the rays to a focus on the retina. On first opening a book, the pa- 
tient for a time is able to read, but the ciliary muscle soon becomes exhausted, 
and relaxing itself, the image is immediately either entirely or partially thrown 
out of focus, and becomes either indistinct or else completely lost. 

''The, eye, examined with the ophthalmoscope, is normal, or, perhaps, the 
fundus may be more pallid than is usual, but there is nothing seen to account 
for the great impairment of vision which exists. It is to some central change- 
that we must attribute the want of the due appreciation of the images which 
are formed on the retina. The cornea and all the humours of the eye are clear, 
and light is freely admitted within the globe, and yet the patient fails to see. It 
may be that the brain is deprived of some of the elements essential to its proper 



1861.] 



Ophthalmology. 



285 



nutrition by the drain which excessive lactation produces in the mother, and that 
for the want of a better term we must attribute it to an exhausted nervous 
energy. 

"But if this affection advances, further changes undoubtedly take place, and 
in addition to the patient losing, to a great extent, the power of focusing the 
eye for more than a short time for near objects, or requiring continually to re- 
adjust itself, the retina becomes somewhat insensible to the images which are 
formed upon it, and from at first only appreciating large and dark objects, it 
gradually ceases to take cognizance of them at all, and a state of amaurosis is 
established. It is difficnlt to estimate the cause of this amaurotic state, or to 
ascertain what are the pathological changes which produce it. That this 
amaurotic condition is dependent on suckling is proved by the fact that it can 
be greatly relieved, and often cured, if properly treated ; first, by weaning the 
child ; and secondly by the free use of those tonics which seem to have a spe- 
cial action in invigorating and restoring tone to the nervous system. 

" Some women can never for any length of time suckle their children, for after , 
a few weeks, or months, the eyes become affected, and the impairment of vision 
increasing, they are compelled to cease. 

" If, in spite of the continuance of the symptoms, the woman continues to nurse 
her child, the case may proceed from bad to worse, and what at first was only a 
functional disease, may ultimately become an organic one, from atrophy and 
waste of the parts from want of use, and the eye, which originally exhibited no 
abnormal appearance, may assume the peculiar condition of one which has long 
been deprived of its power of sight, and the large bluish-white optic disk, with 
the shrunken and thready retinal vessels and the patches of atrophied choroid, 
indicate that changes have taken place which give little hope for future re- 
covery." 

In the treatment of these cases, Mr. L. says : " The first and manifest course 
to be adopted is, if the case is a severe one, at once to remove the exciting cause, 
and to order the mother to wean the child. If the case is one of choroidal con- 
gestion, attended with some photophobia, the patient should be prevented ex- 
posing her eyes to strong light ; the room in which she sits should be slightly 
darkened, and she should not be allowed to use her eyes, either in attempting to 
read or to do any needlework. She need not confine herself to the house, but, 
on the contrary, a moderate amount of out-door exercise will do good, but the 
eyes should be protected from any strong sunlight by wearing a pair of cobalt 
blue glasses, of any shade which she finds most comfortable. The frequent 
application of cold is often a source of relief, and this may be applied either by 
cold sponging, or else by a douche, using it with the lids gently closed, four or 
five times during the day. The bowels should be carefully regulated with pil. 
hyd. c. colocynth. or some other mild alterative. It is seldom that a mercurial 
course is required, indeed there is no indication for such a line of treatment, 
unless the congestion of the choroid has extended to the iris, and a chronic 
choroido-iritis has been established, in which case mercurials are undoubtedly 
called for, but quinine should at the same time be freely administered. In all 
cases quinine with iron seems to be the medicine which affords the greatest re- 
lief, or it may be given alone if the iron is not required. In some cases where 
there is a condition of great ansemia the mist, ferri comp. is a most valuable 
medicine. 

" In the second class of cases, in which the eye itself evidences no internal 
congestion, but the impairment of vision appears to be cerebral, very much the 
same line of treatment is required. Weaning the child, absolute rest to the eye, 
good diet, and the free exhibition of steel and quinine are the remedies which 
afford the patient the greatest benefit, and which generally succeed in restoring 
perfect sight to the patient. The class of cases which seem to derive no benefit 
from treatment are those in which there has been a long impairment of vision, 
and suckling has still been continued ; when, in spite of repeated warnings, the 
mother has still continued lactation ; and when, as the result of such imprudence, 
some organic change has taken place either in the nervous apparatus of the eye 
itself, or in that part of the brain with which the eye is associated. That this 
change may be molecular, and to us at present inappreciable, is possible, but the 



286 



Progress of the Medical Sciences. [July 



fact of our not being able to understand what lesion exists, does not forbid the 
idea of one being present." 

36. Hypertrophy of the Connective Tissue of the Optic Nerve in Relation to 
Albuminuric Amaurosis. — A case which is of much interest with respect to the 
occasional complication of amaurosis in albuminuria, has been recently com- 
municated to the Medical Society of Sweden, by Professor Malmsten and Dr. 
Gyllenschjold. 

It was that of a man, sixty-six years of age, who had suffered for several years 
from albuminuria. After having suddenly lost the sight of the right eye this pa- 
tient wa's affected in a similarly abrupt manner three days subsequently with very 
marked amblyopia in the left eye. Objects of a large size could alone be dis- 
tinguished, and this condition, which was not accompanied by any lesion appre- 
ciable with the aid of the ophthalmoscope, continued until death. 

Upon making a post-mortem examination the kidneys were found to be waxy 
and enlarged. The retinae were not the seat of any of the morbid appearances 
which have been noticed by numerous observers in albuminuric amaurosis, but 
the two optic nerves were completely destroyed at the point of entrance through 
the sclerotic by a peculiar substance composed of connective and elastic tissue. 
This mass, in which the nervous filaments were found, as it were, smothered, 
commenced in the neurilemma, at the border of the sclerotic, and was continued, 
under the form of fibrous strings, between the nervous filaments. 

Professor Malmsten stated that he had found this singular deposit in three 
persons who had become amaurotic at an advanced period of B right's disease, 
and in whom the retinas and other parts of the eye presented no abnormal ap- 
pearance. 

Apart from theecchymosis and infiltrations into the retina occasionally noticed 
in albuminuric amaurosis, this injury to the optic nerve deserves the attention 
of the physician as one of the causes of that complication of B right's disease, the 
relative importance of which remains to be determined. 

In alluding to the observations of Professor Malmsten, the " Gazette Heb- 
domadaire" draws attention to the cases published last year by M. Graefe, in 
which the hypertrophy of the interstitial cellular tissue of the optic nerve, with 
sanguineous injection, was consecutive to intercranial tumours and to cere- 
britis. — London Med. Rev., May, 1861. 



MIDWIFERY. 

37. Treatment of Cases of Abortion in which the Membranes and Placenta 
are retained. — Dr. W. 0. Priestley read a very interesting paper on this 
subject, before the Obstetrical Society of London (May 1, 1861). The author 
began by observing that when abortion occurs in the early weeks, the ovum is 
frequently expelled without rupture of any of the membranes except the external 
decidua, because the attachments to the uterine cavity are unstable ; the mass 
is then smaller and less difficult to push through the os uteri, and the contrac- 
tile power of the uterus is very feeble. In the third, fourth, and fifth months 
the decidual cavity is obliterated, the placenta has acquired more intimate 
attachments to the womb, and the contractile power of the uterus being greater, 
rupture of the membranes commonly takes place before expulsion. The embryo 
having escaped, the secundines may speedily follow, or, lying in the os uteri, 
they may be removed by the finger or some simple instrument. In a consider- 
able number of abortions, however, in which the foetus and liquor amnii have 
been voided, the secundines are not soon extruded ; and after the uterus has 
made repeated ineffectual attempts to expel them the os uteri closes and action 
ceases. Instances of this kind are common in obstetric practice, and are often 
a source of much embarrassment to the practitioner. Obstetric authorities differ 
widely as to the treatment which ought to be adopted when the secundines are 



1861.] 



Midwifery. 



28? 



not thrown off spontaneously, and particularly as to the propriety of manual 
interference. Dr. Denman, Dr. Davis, Dr. Ramsbotham, and Dr. Dewees de- 
precate any attempts at extraction by the hand ; and Mr. Ingleby held that "no 
manual extraction can be effected prior to the sixth month." Dr. Burns and 
Dr. Churchill regard interference in this way as only allowable in exceptional 
cases : and Dr. Tyler Smith stands almost alone in recommending the removal 
of the secundines in all cases of abortion where they are retained. The author 
regarded the question of treatment as an important one to all obstetric practi- 
tioners, as they might be blamed on the one hand for omitting a duty they ought 
to have performed, or on the other hand might be charged with meddlesome 
practice. He had met with a considerable number of patients, who had seriously 
suffered from placental retention, and this had induced him to bring the subject 
before the society for the purpose of eliciting opinions as to the proper course 
which ought to be followed. The dangers and morbid conditions arising from 
membranous and placental retention were stated to be : — 

1. Flooding ; this being sometimes of a very serious character, and the patient 
being always liable to hemorrhage so long as the fragment remains. 

2. Decomposition of the uterine contents, leading to local inflammation of the 
uterus and surrounding tissues, to phlebitis and phlegmasia dolens, and lastly 
to general poisoning of the system, as evidenced by irritative fever, peritonitis, 
rheumatic pains, the formation of abscesses, and even the occurrence of death. 

3. Sub-involution of the uterus. 

4. The generation of some of the forms of mole out of the tissue left in the 
uterine cavity, and the hemorrhage attending the presence and expulsion of these 
morbid growths. 

The entire absorption of the placenta was regarded as uncertain and not to 
be counted upon. Cases illustrative of the several sources of danger were de- 
tailed. 

In considering the various methods of treatment which have been recom- 
mended, the author's experience led him to believe that the effect of the admi- 
nistration of ergot was very uncertain, and that galvanism and injection of water 
were not to be depended upon. Any form of abortion-forceps which must needs 
be pushed beyond the reach of the finger he regarded as useless and dangerous. 
He was thus driven to the conclusion that the introduction of one or two fingers 
into the uterus was the safest and best way to remove the retained uterine con- 
tents. In his hands such manual interference had never been followed by any 
evil results, and a considerable number of cases had fallen under his observa- 
tion. He begged particularly to be understood as not advocating rash and 
violent attempts to empty the uterus. Rough and careless manipulation might 
be fatal to a patient ; but the consequences of placental retention were so seri- 
ous that, under ordinary circumstances, less risk was incurred by the operation. 
It was important to effect removal, not only before putrescence began, but be- 
fore the os uteri became much contracted ; and if in six hours after the escape 
of the embryo the placenta did not follow, it might be removed. The extraction 
might be effected sooner than this if much hemorrhage were present. He had 
found it convenient in operations to place the patient on the back, with the 
thighs flexed on the abdomen ; and while one hand steadied and depressed the 
uterus externally, the other was with all possible gentleness passed into the 
vagina. The os uteri was then dilated with the index-finger, and the second 
finger followed if required. These two fingers formed the best and most sensi- 
tive forceps, and although time and care might be necessary to their introduc- 
tion, their employment was most satisfactory. The administration of chloroform 
previous to the manipulation afforded great assistance by relaxing the passages 
and saving the patient from pain. The author had succeeded in removing the 
placenta with the hand in some cases days and weeks after the escape of the 
foetus ; but he had never ventured on any such attempt if inflammatory symp- 
toms and irritative fever had already set in. Where the os uteri was too con- 
tracted to permit the introduction of the finger for the removal of a placental 
mass, its dilatation could be effected by sponge tents, which had the double 
advantage of staying hemorrhage and facilitating the passage of the finger. 

In the discussion to which the reading of this paper gave rise. Dr. Tyler 



288 Progress of the Medical Sciences. [July 

Smith said that in rare cases, the placenta was no doubt absorbed after abortion. 
But the chance of such an occurrence ought not to be allowed, as it led to 
hemorrhage, and infection of the system by putrid matter. The number of in- 
struments devised to extract the placenta showed how important the matter was 
in practice ; but nothing yet produced was equal to the hand and finger. He 
had always taught that in abortions occurring even before the formation of the 
placenta, the thickened decidua should be removed, if it remained and caused 
excessive draining, after the passage of the embryo. In the early months, the 
uterus was only partially developed, so that its expulsive action was compara- 
tively feeble, and the difficulty was often increased by adhesion of the decidua 
and after-birth from disease. In later abortions, he always removed the placenta 
as soon as its retention produced mischief. It was seldom necessary to pass 
more than one finger to detach and hook down the retained mass. In some 
cases, the whole hand required to be passed into the vagina; in others, the 
uterus was sufficiently low to admit of the passing of the finger without this. 
Chloroform was often of great value in promoting dilatation of the osteum vaginae 
and os uteri, particularly in cases where the retention had lasted several weeks, 
or even months. He had not seen any mischief follow the removal, but the con- 
trary. The conditions were that the hand should be clean, and the proceeding 
without violence. He might mention that in cases of flooding after delivery at 
the full term, when the placenta had been expelled, he had frequently passed 
the hand into the uterus to remove portions of membrane which were apt to 
separate from the placenta and remain in the uterus, or hang from the os. Many 
of the worst cases of flooding met with in practice were, he believed, of this kind, 
and to clear out the uterus was the only effectual way of stopping the loss of 
blood.— Lancet, May 11, 1861. 

38. On the Length and Weight of New-horn Infants. — Dr. E. von Siebold, 
of Gottingen, has been accustomed to carefully weigh and measure all the new- 
born infants at the midwifery institutions with which he has been connected 
from the beginning of 1852, his chief object being to ascertain whether the state- 
ment is correct that new-born infants lose weight during the first days after 
birth, afterwards regaining and augmenting it. Not only may such investiga- 
tions prove of importance in this obstetrical relation, but also as regards phy- 
siology and juridical medicine. Weighing children has been employed in these 
midwifery institutions to determine how far artificial feeding would be tolerated, 
whether an illness of the mother is acting injuriously on her child, and as one 
element in the choice of wet-nurses. Dr. E. von Siebold first presents a table 
of the weights of 3000 infants (1586 male and 1414 female) , weighed immediately 
after birth. From this table (for which we have not space) it results that by 
far the greater number of the children (2215) weighed between 6 and 8 pounds. 1 
From 5f to 6 lbs. the numbers rose from 99 to 268 ; and from 8 to 8| lbs., they 
fell from 226 to 67, and never rose again at any weight to 100. From 8f to 9| 
lbs. they sank from 61 to 8, rising, however, at 9|- lbs. to 21. Only 6 weighed 
10 lbs., one lOf lbs., and two 11 lbs. The author has never but once met with 
a child weighing llf lbs. The most frequent weight in the 3000 was 7 lbs., 
numbering 426. It is a remarkable fact, that until the weight of 7 lbs. the female 
infants exceeded the males in number, the latter thenceforward predominating. 
This agrees with Scanzoni's figures, who found that the weight of the male in- 
fants in 9000 births averaged 7 lbs. gij, or giij ; and of female infants, 6 lbs. 
gxxviij, the female infants weighing less than 7 lbs. more frequently than the 
males. From these statements and those of various other writers here quoted, 
the conclusion may be drawn that the normal weight of a mature new-born in- 
fant is not less than 6 nor more than 8 lbs., the average weight being 6j or 7 lbs., 
the smaller number referring to female, the higher to male infants. 

Chaussier and Quetelet have already shown that for the first few days after 
birth a diminution in the weight of the infant takes place, and since the begin- 
ning of 1859 the author has paid much attention to this subject, having care